JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 8 Feb 2007

Water Fluoridation: Discussion with Expert Body on Fluorides and Health.

Chairman

I welcome Dr. Seamus O'Hickey, chairman of the expert body, Dr. Brian O'Herlihy, vice chairman, Mr. Stephen McDermott, Professor Denis O'Mullane and Ms Martina Queally.

I draw the attention of witnesses to the fact that members of the committee have absolute privilege but that this does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice that they 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 invite Dr. O'Hickey to introduce the delegation and to give the committee an overview.

Dr. Seamus O’Hickey

I thank the committee for inviting us to talk to members.

I am joined by the vice chairman, Dr. Brian O'Herlihy, who is a specialist in public health medicine and director of public health in the eastern region, and Professor Denis O'Mullane, who is a member of the expert body. He is an internationally recognised expert in the field of health services research, which includes fluorides. Ms Martina Queally is a member of the communications and public health promotion sub-committee. Mr. Stephen McDermott is chairman of our quality assurance sub-committee, which addresses on an ongoing basis the use of fluoride as an established health technology.

I will be brief, as I know the committee members have questions to ask us. The expert body was appointed by the Minister for Health and Children in 2004 and its terms of reference can be summarised as follows: to oversee the implementation of the recommendations of the forum on fluoridation; to advise the Minister and to evaluate ongoing research including new emerging issues in research on all aspects of fluoride, its delivery methods and technology and as required by the Minister; and to report to the Minister on matters of concern at his or her request or on our own initiative.

The expert body is comprised of 26 independent specialists across a range of disciplines which include dentistry, public health medicine, paediatrics, biochemistry, engineering, diet, nutrition, management, environment, as well as consumer-related representatives. Our remit includes advising the Minister and evaluating ongoing research on all aspects of fluoride and its delivery as an established health methodology.

Science drives and influences our opinions and we maintain that water fluoridation in Ireland is one of the most beneficial health care policies the State has ever undertaken, providing immense benefits to all sections of society, irrespective of their social status.

Chairman

I thank Dr. O'Hickey. Rather than group questions I will take questions to be answered individually.

Deputy Gormley

I welcome the delegation, as I was anxious to have its members come before the committee. Is Dr. O'Hickey familiar with a report published in 1997-98 on research carried out in Trinity College to examine the fluoride content of popular infant formulae and milks and to study the fluoride dose being received by infants from these various sources? Is he aware of its recommendation, which states clearly that baby formulae should be reconstituted with non-fluoridated water?

Dr. O’Hickey

This report was produced by a student group. In the Trinity College dental school we require our fourth-year students to undertake various research projects under supervision and this was such a student project. Those were their findings but I would not lend any great weight to it. It was presented at a scientific meeting as a presentation but it was never published in any scientific journal that I am aware of.

Deputy Gormley

Professor Clarkson of Trinity College would not be regarded as a student.

Dr. O’Hickey

Professor Clarkson would have been the supervisor of that group. If I am correct, at the time he was a professor of dental public health in the college.

Deputy Gormley

Dr. O'Hickey will be aware of an article by Professor John J. Clarkson and Jacinta McLoughlin of the school of dental science, Trinity College, Dublin, published in an international journal in 2000. The article states, "However, infant formulas should still be prepared using non-fluoridated water". Is this correct?

Dr. O’Hickey

I presume that is correct. I am not aware of the details of the particular article.

Deputy Gormley

Was Dr. O'Hickey's name not associated with that article?

Dr. O’Hickey

I would probably have been associated with it because I was a member of that particular group in the faculty of dentistry in the college. Professor Clarkson would have been the head of the department, Jacinta McLoughlin was next in line, and I was there as a part-time teacher. My association with that article was very peripheral but I was aware of it at the time.

Deputy Gormley

I can tell Dr. O'Hickey that his name is associated with the article and it is there very clearly.

The article clearly states that infant formulae should still be prepared using non-fluoridated water. Does Dr. O'Hickey accept this was printed in a peer-reviewed——

Dr. O’Hickey

What was the date of that article?

Deputy Gormley

It was in 2000. I will give the reference. It is the International Dental Journal 2000, volume 50, No. 3.

These people are not students but are recognised experts and the article was peer-reviewed. Does Dr. O'Hickey accept that this statement was published at the time?

Dr. O’Hickey

It was a student project which was supervised——

Deputy Gormley

I am saying that Professor Clarkson is not a student and he wrote this article along with Jacinta McLoughlin. Does Dr. O'Hickey accept they wrote this article?

Dr. O’Hickey

They were the joint authors.

Deputy Gormley

Does Dr. O'Hickey accept this is what they said at the time?

Dr. O’Hickey

I presume my name was on the article too. I accept what the Deputy is saying.

Deputy Gormley

If they said that at the time, I would consider that to be quite significant. Was the opinion communicated in any way to the Department of Health and Children that fluoridated water should not be used to reconstitute baby formula?

Dr. O’Hickey

There would not have been any direct line of communication between the people in the dental school and the Department of Health and Children. I am sure the Department officials would be aware of what arises in the literature. I believe they have a dental adviser in the Department.

Deputy Gormley

The Department does not currently have a chief dental officer but it did at the time. Was this information communicated to the chief dental officer in any way?

Dr. O’Hickey

I am not aware that it was but I am not aware that it was not either.

Chairman

There is no obligation.

Dr. O’Hickey

No, there is no obligation.

Deputy Gormley

Dr. Wayne Anderson of the Food Safety Authority of Ireland's scientific committee came before this committee on a previous occasion. Is Dr. O'Hickey aware that nine members of the committee met and agreed unanimously that baby formula should not be reconstituted using fluoridated water? Is Dr. O'Hickey aware that this was their initial decision?

Dr. O’Hickey

I was aware of that, but only as second-hand information.

Deputy Gormley

Is Dr. O'Hickey aware that this decision was subsequently changed when, according to Dr. Anderson, some of the people changed their minds?

Dr. O’Hickey

In a very informal way I inquired as to what had happened and I was told there was a mathematical error in the calculations in the paper they had produced and that it had to be re-written. When it was re-written it was changed.

Deputy Gormley

I will put this question to all the members of the delegation. Dr. Anderson said in September 2002: "One member of the committee who had not been present insisted on re-opening the discussion and the decision was reversed on the grounds that bottle-only feeding lasts only a few months and is finished well before the formation of adult teeth begins". When he appeared before this committee he said that some people had changed their minds. It is a difference between "one" and "some".

Dr. O'Hickey works with Dr. Anderson and would have close knowledge of what went on. Some of the witnesses have close knowledge of what went on. Who was that person, or who were those persons?

Mr. Stephen McDermott

I can say quite honestly that I have no idea who the person was who changed the ——

Deputy Gormley

While Dr. McDermott may not know, would Professor O'Mullane know?

Professor Denis O’Mullane

I do not know. All I know is that when the issue came up at the expert body in the initial reports, I was asked to comment. I mentioned that if the calculations and the conclusions arrived at in the initial paper were correct, we would be seeing very high levels of dental fluorosis in Ireland. The calculations and conclusions reached did not match what I was seeing as an epidemiologist of dental fluorosis. I raised the question that this should perhaps be reconsidered.

Deputy Gormley

Is the professor saying that he raised this? We are trying to identify the person because it was an unusual change of position. Who was this person that changed people's minds?

Professor O’Mullane

I only intervened at this stage because Deputy Gormley asked me to comment on the initial finding. That is my recollection of what went on.

Chairman

Why do we need to know the person? What is the Deputy trying to get at?

Deputy Gormley

The Chairman will agree that for a committee of any sort to agree initially and then change its mind on the basis of one person not being present at a meeting is most irregular. I am trying to establish who the person was so that we can get to the bottom of it.

Professor O’Mullane

If a scientific paper is incorrect, it is totally appropriate that the calculation be done correctly. The correct calculation was done. It has been published in a scientifically reviewed article in one of the most eminent international journals, Caries Research. That paper is available to the committee. It contains the calculation that should have been conducted initially.

Deputy Gormley

I wish to be very clear. Does Professor O'Mullane know the identity of the person? If he does not know, that is fine, if he does——

Professor O’Mullane

I have no idea who communicated with Dr. Anderson on this matter. All I know is that I raised a very serious query about the actual estimate that was used. As a result I understand that Dr. Anderson, or I do not know who else——

Deputy Gormley

We are asking this question because last week we asked the Chairman to send a letter to the Food Safety Authority of Ireland. We asked specifically for this question to be answered and it was not answered. That is the background.

I know Professor O'Mullane wants to deal with the FSAI study and we will come to the technical details now. What is the safe exposure at which dental fluorosis is unlikely to occur?

Professor O’Mullane

It would be 0.04. It is always dangerous to give figures. I am usually reluctant to do so. The figure is well publicised in the literature. It is somewhere between 0.04 and 0.07. A person named Hong published an article in which a large number of people in the state of Iowa in the US were monitored, leading to a very definitive conclusion on the link between the amount of fluoride taken in at a critical period between the ages of one year and two years, and the subsequent appearance of the changes in teeth. A study is ongoing in Cork monitoring the exact amount of fluoride being taken in every day by 78 babies solely fed with infant formula. In 2002 a study was undertaken at the request of the forum in order to establish the relationship between infant feeding practices and dental fluorosis in primary teeth. That study has been published.

Deputy Gormley

I have read it.

Professor O’Mullane

No link was found between infant formula feeding and dental fluorosis.

Deputy Gormley

Would Professor O'Mullane agree that the safe exposure is approximately 0.05 mg per day? That is the international figure that I have seen.

Professor O’Mullane

I am reluctant to get into exact recollection of figures. It is to do with milligrams per kilogram of body weight.

Deputy Gormley

It is the amount per kilogram of body weight per day.

Professor O’Mullane

That changes as the baby grows. Therefore this is very technical. I am very happy to write it down. It is somewhere between 0.04 and 0.07 mg per kg of body weight. That is the best information I can give at this stage.

Deputy Gormley

Is Professor O'Mullane aware of the tolerable upper intake level for fluoride as set by the Institute of Medicine in the United States?

Professor O’Mullane

The tolerable upper intake and the various upper limits are very complicated. I am aware of them.

Deputy Gormley

Can the Professor tell the committee what the tolerable upper intake limits are?

Professor O’Mullane

No, I will not. If I had the publication before me, I would. I am not willing to give them at this stage. They are well established and are published. There is no mystery about them.

Deputy Gormley

I have a figure for the tolerable upper intake limit, which I believe to be correct. Professor O'Mullane may be able to confirm whether it is correct. It is 0.1 mg per kg per day.

Professor O’Mullane

That is quoted in Dr. Anderson's published article. I am not too sure whether that is the correct figure. Again, I do not have the article with me. I beg the Chairman's protection here. It is seriously dangerous for me to make——

Chairman

Either way, there is nothing secret about it.

Professor O’Mullane

Nothing at all.

Deputy Gormley

Does Professor O'Mullane accept that we can see moderate dental fluorosis with a daily fluoride level of more than 10 mg per kg body weight per day?

Professor O’Mullane

One would certainly see considerable fluorosis if one had that level.

Deputy Gormley

I meant to say 0.1 mg per kg body weight per day.

Professor O’Mullane

That would be very high. Is the Deputy missing a zero?

Deputy Gormley

The figure is 0.1. I am sorry if it is technical. I am dealing with technical matters and I also need to get it right.

Professor O’Mullane

I am very happy to give the committee a very scientific answer. If 0.07 was the figure I gave earlier, then 0.1 would not be far from it. I am not sure of the point the Deputy is making.

Deputy Gormley

I return to another point. I believe Professor O'Mullane referred to Professor Levy.

Professor O’Mullane

Absolutely.

Deputy Gormley

He has done considerable work. Do I understand that he came to Professor O'Mullane's institute in September?

Professor O’Mullane

He has come a few times. We collaborate frequently.

Deputy Gormley

Was he here in September?

Chairman

We do not need to know exact dates. The Deputy is putting people under pressure on specifics that they are not able to provide. Does it matter if it was July, August or September? He was here.

Deputy Gormley

It does. If I know he was here in September, I can get the information.

Professor O’Mullane

He probably was here, because there was a big scientific meeting in Dublin.

Deputy Gormley

Thank you.

Professor O’Mullane

Some of the material relevant to this issue was presented at that meeting. Professor Levy's team presented a number of papers.

Deputy Gormley

All right.

Professor O’Mullane

He also participated in a special conference that was organised in association with that meeting.

Deputy Gormley

I would like to ask about Professor Levy's work. I refer to a paper called Timing of Fluoride Intake in Relation to Development of Fluorosis on Maxillary Central Incisors. Is that Professor Levy's paper?

Professor O’Mullane

What date was it published?

Deputy Gormley

It was submitted on 19 January 2005. Is Professor Levy, who is regarded as the foremost expert in this area, saying that fluoride intakes are very significant during each of the first four years? Is he saying that the intake is very significant, especially in respect of fluorosis of the permanent dentition, during the first year?

Professor O’Mullane

He is not saying that. He has more or less come to the end of the Iowa study, as it is called. He is saying that a contribution to dental fluorosis was made in each of the four years in which he followed the children. It was previously thought that the critical period was between 16 and 24 months. He is saying that is not incorrect. There is some contribution from the first year. I would have to read the paper again. I may have it with me. He is certainly not saying that the first year is more important than any other year.

Deputy Gormley

The paper states that "results suggest that the middle of the first year of life is most important in fluorosis etiology for the primary dentition in this setting".

Professor O’Mullane

The Deputy's previous question——

Deputy Gormley

It was about permanent dentition.

Professor O’Mullane

——related to permanent dentition. I am confused.

Deputy Gormley

That was the 2002 paper.

Professor O’Mullane

Correct.

Deputy Gormley

Professor Levy's 2005 paper seems to suggest that the intake of fluoride is important in the fluorosis of the permanent dentition.

Professor O’Mullane

He is not saying that. He is saying that the conclusion arrived at by Evans and Stamm 12 years earlier was not that incorrect. In other words, the question of fluorosis in primary teeth is a different one. We are now talking about dental fluorosis in permanent teeth.

Deputy Gormley

Yes.

Professor O’Mullane

It is not correct to say that the first year of life is the important one in terms of fluorosis in permanent teeth. As far as I know, that was not concluded in that series of——

Deputy Gormley

Professor O'Mullane is telling the committee that as far as he is concerned, it is not the most important time.

Professor O’Mullane

No, it is not.

Deputy Gormley

I am just trying to clarify what Professor O'Mullane is saying.

Professor O’Mullane

He counts it in months, so I have to divide it by 12.

Deputy Gormley

All right. Is Professor O'Mullane aware that the American Dental Association has issued a document called Interim Guidance On Reconstituted Infant Formula? The association has advised that infant formula should not be reconstituted using fluoridated water. Does Professor O'Mullane think that was good advice to give to parents in the United States? The interim guidance to which I refer was issued on 9 November 2006. The association said it would be advisable for parents not to use fluoridated water to reconstitute baby formula. Was that good advice to give to parents?

Professor O’Mullane

I hesitated before I answered because I am not sure that the American Dental Association's statement is worded in the manner suggested by the Deputy. I think the statement says that parents "should consider" using——

Deputy Gormley

I have a copy of the statement. What does Professor O'Mullane think the statement says?

Chairman

This is getting——

Deputy Devins

How can Professor O'Mullane be expected to know what the document says when he does not have it in front of him?

Deputy Gormley

I have the document in front of me.

Deputy Devins

Why did the Deputy ask the question then?

Deputy Gormley

Professor O'Mullane said he does not think the document says what I think it says.

Chairman

I ask Deputy Gormley to read the relevant section of the document.

Deputy Gormley

The American Dental Association's document states that "if using a product that needs to be reconstituted, parents and caregivers should consider using water that has no or low levels of fluoride".

Chairman

It says "should consider".

Deputy Gormley

Right.

Professor O’Mullane

I was correct to say what I said. I knew very well that such a phrase was included. I was reluctant to agree that the American Dental Association had said that parents "should" rather than "should consider". The circumstances in the United States which are assessed by the association are different to those in Ireland. Earlier in the document, the association mentions that the naturally occurring levels of fluoride in water in many parts of the United States are considerably higher than the 0.9% target level in Ireland. If the association is giving advice in a global sense to the American public, I would agree with the statement in question.

Deputy Gormley

Yes.

Professor O’Mullane

I do not agree that it would be the correct advice to give to the parents of infants in Ireland because the fluoride in the water here is, under regulation and law, contained within a certain level. It is different situation. The American Dental Association said that parents "should consider" taking a certain approach.

Deputy Gormley

All right. To what extent is water in the United States fluoridated? Is it not done at a similar level to that in Ireland? Do they not fluoridate at the same level as we do?

Professor O’Mullane

The level of fluoride in the water differs substantially throughout the world, depending on the mean annual daily temperature. Generally speaking, the US works off the same formula as us. The point I am making about the situation in the United States relates to a previous document — I get confused with all these bodies in the US — which mentioned that the upper level that they would regard as reasonable was four parts per million. High levels of fluoride naturally occur in the water in many parts of the United States. When a body such as the American Dental Association issues advice to its membership — it has more than 100,000 members — it has to take account of the fact that the levels of fluoride in the water supply in many parts of the US are considerably higher than in other parts of the US.

Deputy Gormley

Why is more fluoride added to the water supply in those parts of the US which have naturally occurring fluoride levels?

Professor O’Mullane

No, they do not do that. There are three categories of people in the world — people who live in communities with no fluoride in the water, people who live in communities with too much fluoride in the water and people who live in communities with the optimal level of fluoride in the water. Skeletal fluorosis, which is caused by excessive consumption of fluoride, is a major problem in many parts of China and Africa. To achieve the optimal level of fluoride in the water, it has to be artificially adjusted upwards or downwards. Communities which already have a fluoride level of four parts per million do not add more fluoride to the water.

Deputy Gormley

Is Professor O'Mullane saying that the advice that was given by the American Dental Association was aimed at people living in communities which are naturally fluoridated?

Professor O’Mullane

I do not know. I was not party to the association's discussions on its target population. I am not trying to be——

Mr. McDermott

Natural fluoridation can lead to relatively high concentrations of fluoride in the water. We are talking about fluoride levels which are four times in excess of the legal maximum limit in Ireland.

Deputy Gormley

In some cases.

Mr. McDermott

In some cases, yes. When one gives advice like that of the American Dental Association, one has to give advice for extreme circumstances, not just for the mean circumstances.

Deputy Gormley

I have to say that my reading of the advice that was given to parents in this instance is that it did not make any distinction between areas which are artificially fluoridated and areas which are naturally fluoridated. It is clear parents who live in fluoridated areas should consider this advice. In fluoridated areas in the United States the same level of fluoride is used as is used here.

Professor O’Mullane

In that document there is a section dealing with naturally occurring fluoride in the United States. My contention is the advice was given in the context of the fact that there was a reference in the same document to communities which have more fluoride in the water supply.

Deputy Gormley

Why did Professor Clarkson give the same advice here?

Professor O’Mullane

The question of Professor Clarkson's contribution was——

Deputy Gormley

No, it was not. With respect, Professor Clarkson, who is respected here, gave exactly the same advice, namely, that baby formula should not be reconstituted using fluoridated water. That was published in a prestigious dental magazine in the year 2000. Why did he give exactly the same advice?

Professor O’Mullane

I do not know.

Deputy Gormley

He was at the fluoridation forum.

Professor O’Mullane

All I know is that Dr. Wayne Anderson did a calculation on the basis of the estimated intake of fluoride from infant formula by babies in Ireland and it was published in an international journal. That conclusion was rigorously and thoroughly assessed by international referees. We are also carrying out a study of 78 babies in Cork based on the exact amount of fluoride taken in by them. Currently, the estimate by Dr. Anderson is there is no problem with infant formula.

The study we published with Mairéad Harding in an international journal shows there is no difference in the amount of fluorosis in primary teeth between babies fed with infant formula in comparison with babies who are breast-fed. We have funding which will allow those children to be followed up when they get permanent teeth at the age of, approximately, eight years. We will then be in a position to support this view further but currently there is no evidence to support the contrary position.

Deputy Gormley

This is my final point. I can quote Professor O'Mullane many studies showing that is not the case. I will not delay the meeting by quoting them but I will circulate them to my colleagues. If one looks at the FSAI analysis quoted by Professor O'Mullane, one sees that most infants bottle fed with formula will exceed the dosage of fluoride that can cause moderate dental fluorosis. That is my reading of it. Moreover, 5% of infants will receive more than 0.2 mg per kilogram body weight per day. That is double the IOM's upper tolerable limit. Professor O'Mullane can dispute this view but that is my reading of it.

Deputy F. O’Malley

Is fluoridated water in the Untied States at the same level as here or is it as much as five times our level?

Mr. McDermott

They permit public water supplies in naturally fluoridated areas to be four times greater than the legal limit in Ireland, which is 1 ppm, part per million. Our limit is less than the legal limit anywhere else in Europe which is 1.5 ppm. We are already at the safe end of the margin.

It is important to state we are talking about dental fluorosis as a minor cosmetic issue. The extremes in some areas of the world are as a result of a serious problem with very high levels of fluoride which would not be acceptable for human or even animal consumption in Ireland. Dental fluorosis at the levels reported in repeated epidemiological studies is not an issue for people. It is not something that is noticeable, nor is it problematic.

It is also fair to say the forum on fluoridation, of which I was not a member, looked at those increasing levels of questionable and very mild fluorosis and suggested, based on the fact that there are now additional sources of fluoride which were not available in the 1960s when fluoridation was originally introduced, that we reduce the levels from between 0.8 ppm and 1.0 ppm with a target of 0.9 ppm to between 0.6 ppm and 0.8 ppm with a target of 0.7 ppm. Deputy Gormley is quite correct. These facts were taken into account by the forum on fluoridation and the recommendation deals with them.

Deputy Gormley

I will come back to those points.

Chairman

I want to move on. Other members are indicating.

Deputy Connolly

If we did not have fluoridation of water in Ireland, could the expert group convince the nation that it would be beneficial to embark on a mass medication scheme and introduce fluoride to water? It is a fact that one does not have to drink fluoridated water to gain the benefits attached to using fluoride. Washing one's mouth with water containing fluoride gives one the same benefit. There is no benefit attached to swallowing the water.

We read recently about baby products and the advice given to mothers not to mix formula with fluoridated water. Is that theory being knocked on the head? Are mothers aware of the recommended dosage levels according to a baby's weight?

If somebody suggested to the expert group that something should be added to the water in Monaghan to prevent the spread of avian flu, do the members believe he or she would be successful in this endeavour? Will a member of the expert group expand on the concept of mass medication and whether people want it or not?

Dr. O'Hickey made a statement to the effect that he did not doubt the sincerity of the anti-fluoridation lobby but he thought people were being misled by a small number of individuals who gain financially. Will he please expand on that statement?

Professor O'Mullane stated that the spread of decay in society is not even. It is very much a phenomenon of poverty as much as anything else. Is there a link between poverty and fluorosis? We will not always need fluoridation but we have large areas of social deprivation and there is a prevalence of oral ill-health among this group.

Anybody who goes against what is promoted by the State is labelled a crank. We have a world-renowned expert in Dr. Paul Connett. He tabled 50 legitimate questions on the fluoridation of water. I assumed it would have been a simple process to rubbish those questions or do otherwise with them but the fact there has not been an attempt to answer them leads me to believe they have a certain validity. Why have they not been answered? Likewise, I would like to hear why the scientific critique on the fluoridation forum report has not been answered.

Why did the fluoridation forum and the expert body never employ a toxicologist? That does not appear logical. Surely a toxicologist should be involved when one is adding a chemical to water. The statement was made that there is an acceptance that dental fluorosis is a manifestation of systemic toxicity. Could a member of the expert body expand on that point? Is there a reason the only legal expert, Professor William Binchy, never attends meetings of the expert body?

Dr. Brian O’Herlihy

I will reply to some questions from the public health point of view. It is interesting that the legislation in the UK was altered in 2003 to make it easier to introduce fluoridation of the water supply there. Already 10% of the UK population drinks fluoridated water. The number in the United Kingdom drinking fluoridated water is greater than in Ireland and the policy there is to increase that number. Legislation passed in 2003 makes it easier to achieve this. In the United States it has been recognised that the fluoridation of the water supply, because of its impact, has been listed by the Surgeon General among the ten best health measures undertaken in the 20th century.

The Deputy rightly referred to disadvantage and in this regard there is a greater burden of dental caries among this cohort. While most of us regard dental caries as a very minor inconvenient condition if treated early, it can have serious consequences if left untreated. Not only can it lead to severe pain, it can also lead to the extraction of teeth, the disruption of the nutrition process and systemic infections.

From a public health point of view, fluoridation poses no problem with compliance, in the same way as some other public health measures. Those who benefit most are the socially disadvantaged. There are many places where steps are taken for the common good. Worldwide, every major health body that has ever considered the evidence on water fluoridation has confirmed its effectiveness and there is no evidence that fluoridation at the optimal level causes any harm other than dental fluorosis.

Fluorosis, which was originally referred to as "mottling of the teeth", sounds as if it were a disease but it is not. We have widespread fluoridation in Ireland and if one looks at people on the street, one will not see individuals with ugly mottled teeth caused by fluorosis. I am certainly old enough to remember the condition of people's teeth 30 and 40 years ago, at which time elderly people had no teeth of their own. Rather, their teeth were all false. The average elderly person today has many of his or her own teeth.

In ensuring the common good, one could most certainly make a strong case for fluoridation today. In the United Kingdom, where surveys have been done, it has been shown that approximately 70% of the population support water fluoridation when its benefits have been explained to them.

Deputy F. O’Malley

Does Dr. O'Herlihy believe dental fluorosis is a purely cosmetic issue rather than a medical problem?

Dr. O’Herlihy

Yes, in this part of the world. There are parts of the world, including countries in Asia, such as India, where there are very excessive amounts of fluorine in the water, and it is in these parts that fluorosis is a major problem. A problem arises in trying to extract fluoride from the water supply in such areas but this is not the case here, where water is fluoridated at the optimum level, which is one part per million. It does have a very mild cosmetic effect.

I was at a conference last week in the United Kingdom where a consultant dentist made the very interesting remark that, of the small number of cases referred to him by other dentists for treatment for fluorosis, 40% or more have none. He must tell them this and send them back. Even among dentists, therefore, the question of what constitutes fluorosis is rather subjective.

Deputy Connolly

Quite a number of the issues raised have not been responded to.

Mr. McDermott

On the 50 questions, the answers were given and published on the website of the Department of Health and Children, in 2005 I believe. The delay was owing to the fact that questions changed over the period of three years. The answers therefore had to be updated.

Ms Martina Queally

It is important to remember that our health behaviour, such as brushing habits and the intake of sugary snacks, has not changed in the way we would like in Ireland. Fluoride is therefore protecting our teeth. Some of the work being done by Helen Whelton shows that our oral health behaviour has not changed to the extent we would like.

On the role of the expert body, it is not in our interest, or that of anybody else, to rubbish questions. That is not what we set out to do. We take all questions very seriously and our role is to examine the evidence as it presents itself.

Professor O’Mullane

Deputy Connolly asked a number of questions and some have been answered. On the question of poverty, there is no doubt that the level of dental decay, which fluoride is particularly effective in preventing or controlling, is much higher among the less well-off. One of the advantages of a strategy such as water fluoridation is that no compliance is required. In other words, the population as a whole benefits from it, as opposed to tooth-brushing, which is often proposed as a way of reducing dental decay. The problem with tooth-brushing is that toothpaste and brushes cost money. The level of compliance among the people we, as public health workers, would like to help is lower as a consequence.

Evidence demonstrates that the tooth-brushing behaviour of the Irish is considerably less positive in preventing dental decay than in many parts of Europe. As Ms Queally said, the trend associated with snacking behaviour in Ireland is going in the opposite direction to the one public health workers desire. Recent figures show that the level of sugar consumption has increased. Ireland is one of the main offenders in Europe in this regard and we are almost the worst in the world for consuming soft drinks. The actual cause of dental decay has not gone away, although we are succeeding. When one considers strategies to control it, one will recognise the value of water fluoridation.

On Deputy Gormley's remarks, the pattern of sugar consumption in Ireland is one of the worst in Europe.

Deputy Gormley

Sugar consumption has actually declined.

Professor O’Mullane

It has declined marginally but the frequency of consumption has not declined. I published an article which showed that sugar consumption had declined from 45 kg to 37 kg per person per year. This is true but the pattern of sugar consumption, which is important in terms of dental decay, is important. It is not a question of how much one takes but when and how often one takes it. People are now drinking sweet drinks all the time and the frequency of snacking has increased. I did not say that sugar consumption is increasing. I said the pattern of sugar consumption from the point of view of dental decay has got worse.

Deputy Devins

I welcome the expert committee, which meets on a regular basis and will continue to do so. Does that mean the group's work is not finished?

Dr. O’Hickey

No, we must carry out our remit as it appeared in the report of the forum on fluoridation. We were appointed by the Minister, who also asked me to take over the chair. We then decided that our work would be best done by five sub-committees which report every couple of months to the main plenary meeting. The people present represent the committees and I represent the executive committee. Our work is done on a continuous basis.

Deputy Devins

That was what I wanted to know, that the committee consistently reviews the information available and if new information comes to light, that it will make recommendations on that basis.

Dr. O’Hickey

We are more proactive than that. We seek information and where such information is lacking we ask the health research board or some such body to fund it.

Deputy Devins

Is water fluoridation effective in preventing dental decay? Is it safe? Should it be continued in this country?

Mr. McDermott

We know that since the early 1960s, when fluoridation started in Ireland, the incidence of dental caries has declined by in excess of 40%, a significant difference. Much of that decline took place before any other form of fluoridation was available, so we know it works.

When we compare the Irish population, which has water fluoridation, with populations elsewhere, classically the population of Northern Ireland which is broadly similar in all respects except that it does not have water fluoridation, we do significantly better on all scores related to dental caries. Our scores are 15% better than in Northern Ireland.

Professor O’Mullane

The effectiveness of water fluoridation has been monitored in Ireland since the day the Act was passed. A group was established in 1967 to monitor effectiveness, known as the Mallow-Macroom-Mitchellstown study. I have been monitoring the effectiveness of water fluoridation since then and on each occasion when we have carried out a study, we have found the level of dental decay among lifetime residents of fluoridated communities is considerably lower than that of residents living in communities without water fluoridation. The figures indicate that water fluoridation is effective. The most recent study, conducted by Dr. Whelton, also included Northern Ireland. The 1984 survey was another national survey commissioned by the Department of Health. Each has shown that residents of communities served with fluoridated water have better dental health and lower levels of dental decay than those who do not live in such communities.

Dr. O’Herlihy

On the safety issue, the expert body forms its opinion on the basis of peer-reviewed articles and literature in medical and scientific journals. On that basis and on the basis of the work that has been done by all the international bodies, one can say that it is very safe. Like everything else in this world, however, it is important to keep a watching brief because there is always new information and it is important to keep pace with it. If the situation changed, this would be the first body to make it known and say it should be taken into account. At present, with current levels of knowledge, it is very safe at optimum levels, one part per million, in the water supply.

Deputy Devins

Should it be continued?

Dr. O’Hickey

It might be instructive to look at the history of the introduction of water fluoridation here. The man responsible, the then Minister for Health and Tánaiste, Mr. Seán MacEntee, is long dead. When he wrote his memoirs he highlighted the introduction of fluoridation as a personal triumph on behalf of the Irish people in the health field. He foresaw many of the difficulties we have encountered ever since. This was a political decision taken by a strong personality who was a member of a Government with an overall majority. He had to fight to get it through the Cabinet before he brought it to the parliamentary party and then the Dáil. It remains a political decision as to whether Ireland is to fluoridate its water supplies. We stand on the sidelines trying to be impartial, looking at the evidence in a scientific way and ignoring hearsay.

I said some years ago that no one, including myself, doubted the sincerity of those who opposed fluoridation but that some people had gained financially from it. I had in mind at the time a professor who has since died. He was an American of Greek origin from a fairly obscure provincial university in the United States who made a career out of traversing the world to attend anti-fluoridation meetings. I had him in mind because I had a personal confrontation with him at a meeting and it was apparent to me that he was building a career on this. In my opinion, he was misleading people who were otherwise sincere.

Deputy Connolly

Is it not fair to say that many people in the fluoridation camp made a career out of advising countries to fluoridate? The same charge could be levelled at them.

Dr. O’Hickey

Yes.

Deputy Connolly

It is character assassination to accuse someone of making a career out of anti-fluoridation campaigning.

Mr. McDermott

It was a long time ago. No member of the expert body has any vested interest one way or another.

Deputy Connolly

If members of the expert committee go to South Africa to advise the Government there on fluoridation, we could say they are making a career out of it and are gaining financially.

Dr. O’Hickey

I went to South Africa at the invitation of the South Africans.

Professor O’Mullane

I will answer the original question before addressing the issue of making a career of water fluoridation. On the question of whether it should continue, that is not for me to say, but as an epidemiologist I can show that the most recent study that demonstrates the effectiveness of water fluoridation is such that it gives a considerable advantage from the point of view of dental decay, which is a serious matter to those who reside in fluoridated communities. Those who reside in fluoridated communities will appear to gain considerable advantage from the point of view of dental decay, which is quite a serious matter. For the policy-makers who will decide whether this should continue my figures show that it is effective, particularly when one compares those who live in communities with fluoridated water with those who do not. It is effective to a substantial degree and those who live in such communities have a great advantage, particularly those who are poor.

A couple of communications on the web have accused me of making a career out of water fluoridation. I am glad now to have the opportunity to say that since 1967 I have been measuring the effectiveness of water fluoridation, and in 1980 took up the measurement of dental fluorosis and was the first to report its rising level in Ireland. What can I do? Am I a proponent of water fluoridation if I say it is effective? If I am invited to South Africa to present a paper and I quote figures showing that people who live in a community with water fluoridation have better dental health than those who do not, should I say those figures are lies?

A study is done to one's best capacity. As an epidemiologist I cite the figures and therefore it is important that I report the figures published in many internationally refereed journals which will check their validity. As for making a career of this, some of us are epidemiologists with a particular interest in dental caries and dental fluorosis.

Deputy Connolly

May I ask a brief question?

Chairman

Deputy Devins was in possession.

Deputy Devins

Am I right in saying that the expert group's recommendations are that water fluoridation is effective in controlling the incidence of dental caries, that it is safe, the only known by-product is fluorosis, and that the group recommends that it continue for the foreseeable future unless conflicting evidence becomes available to it?

Mr. McDermott

The answer to all of those questions is "yes".

Dr. O’Hickey

Yes, with the caveat that we have accepted the recommendation of the forum on fluoridation to reduce the level of fluoridation to reduce the level of fluorosis.

Deputy Devins

I was coming to that point. I understood that there was a recommendation to reduce the level. Has that recommendation been implemented? What is its status?

Mr. McDermott

The Department of Health and Children has produced a final draft of the regulation.

Deputy Gormley

The regulation was introduced yesterday.

Mr. McDermott

The regulation has been introduced but I have not seen it. The expert body on fluorides and health worked closely with the Department to advise it on what should be in the regulation. It was a long process.

Dr. O’Hickey

It was long and tortuous.

Mr. McDermott

I am delighted to hear Deputy Gormley say it is now finished.

Deputy Devins

The expert body says there is no problem using tap water here to reconstitute the milk for infant feed.

Dr. O’Hickey

There is no problem at the present level.

Deputy Devins

There are five levels of fluorosis, ranging from zero, which is none, to five, which is most severe. How prevalent are these levels here?

Dr. O’Hickey

Professor O'Mullane is the expert on that subject.

Deputy Devins

I seek only an approximate figure, for example 20% at level three and so on.

Professor O’Mullane

I was given the opportunity to present this information to the committee three years ago when, I think, Deputy Gormley was present. I circulated coloured photographs to illustrate the figures. The categories are: normal, questionable, mild, very mild, moderate and severe. Enamel fluorosis in 12 year old children in the fully fluoridated group is 72% normal, 14% questionable, 9% very mild, 5% mild, 1% moderate and 1% severe. In the non-fluoridated areas in the Republic, 83% are normal, 10% questionable, 4% very mild and 2% mild. These are the grades I presented to the committee. They are on file.

People categorised at the questionable and very mild levels are unlikely to be aware of this issue. Those levels, however, have increased. We have reported that the levels in the 1984 study were lower and that is why the expert body has recommended two main strategies to control enamel fluorosis. One concerns the level of fluoride in the water supply, the regulations for which were apparently introduced yesterday. The second is that guidelines on the use of fluoride toothpaste have been changed. I was glad to see that the recommendations being introduced in the United Kingdom will follow ours in saying that fluoride toothpaste should not be used for very young children because there is no need for it, and that the amount of toothpaste on the toothbrush should be controlled. Several strategies have been introduced to control fluoride.

Deputy Devins

Is Professor Clarkson, to whom members referred, a member of the expert group?

Dr. O’Hickey

Yes. Professor Clarkson is a retired dental academic. He used to be dean of the Dublin Dental Hospital school. Like all members of the expert body he is unpaid. The work is purely voluntary.

Deputy Twomey

According to the briefing notes we received, children in Ireland do not wash their teeth too often and eat too many sweets. Should children's toothpaste carry a prominent warning that it contains fluoride? Should we have a public health campaign contrary to the points made here? If parents wash their children's teeth twice a day and reduce the amount of sweets they eat there is less risk of the children getting dental caries but there is a high risk of their getting fluorosis.

I speak from a personal point of view because even as a general practitioner I know very little about fluoride and its effects. I would have favoured fluoride in water because that is how I was trained. These discussions reveal, however, that the best parents in the country might be doing the most harm to their children because with a public health system that fluoridates water for the benefit of all, children whose parents wash their teeth twice a day with fluoridated toothpaste are at greatest risk of fluorosis. Should we go even further and say that if parents wash their children's teeth twice a day and reduce their sweet intake they should use non-fluoridated toothpaste until their children are 12, 13 or 14?

Another aspect to this issue concerns the amounts of fluoride used and its effects on iodine metabolism and hyperthyroidism. Ireland has high levels of hyperthyroidism. The delegation knows the effects of naturally high levels of fluoride in water in areas in America, China and Africa. Does that relate to what is happening in Ireland? It may not be to the same extent but that there would be significant side effects we should be prepared to talk about.

Many water systems are run either by local authorities or group water schemes which add fluoride to supplies. I note the delegation states levels of fluorosis are quite mild. How often are these systems tested? What bodies monitor water standards? No one wants e-coli in a water supply, yet many supplies are contaminated with it.

Many European countries are against water fluoridation. We cannot dismiss the argument that easily, yet this issue does not stand out. I find it amusing when the delegation quotes what dentists would say. My friends who are dentists would have less knowledge of fluorosis than I have. The same goes for my colleagues in the medical profession. We would have taken the stock answer that everything is rosy and perfect. I was not aware that water is not fluoridated in Northern Ireland. The delegation is fighting on one side of the debate. Over the past several months, there are creeping concerns about this issue. That is why the clearest answers must be given.

Dr. O’Hickey

With respect to Deputy Twomey's opening remarks, fluoride regulations do not apply to voluntary water supply schemes which we recognise as a deficit. It only applies to public water supplies which are applied by sanitary authorities of county and city councils. Voluntary community private water schemes have come under much criticism for micro-organism contamination in water supplies. This is being taken in hand by the Department of Health and Children. That is not our area of expertise so I will not comment on it further.

Mr. McDermott

Testing of water supplies occurs daily by local authority operatives in each water supply. This is then verified and validated on a monthly basis by the Health Service Executive. Environmental health officers take samples on a monthly basis under the Health (Fluoridation of Water Supplies) Act. In addition to this, water supplies are regularly sampled under EU regulations for various chemical parameters including fluoride. We have a very good ongoing picture of the compliance of water supplies with the various regulations. The expert body on fluorides and health has developed a draft code of practice and seeks to combine technology and best practice to bear in water fluoridation. This will be a huge resource for local authority water engineers and plant operatives in respect of how they deal with water fluoridation. It makes recommendations about monitoring, action to be taken in the event that the supplies are not compliant and other matters. This is in a final draft stage and we hope to publish it very soon.

Dr. O’Herlihy

Most research in the west would concentrate on areas with optimum levels of fluoride in water supplies and peer-reviewed articles in medical and scientific journals. Research in this area has gone for the past 40 years. There is no evidence that fluoride at optimum levels causes any harmful health effects other than dental fluorosis. It is quite safe.

Three European countries fluoridate their water supplies — Spain, the UK and Ireland. A greater proportion in the UK drink fluoridated water supplies than in Ireland. The aim is to increase the level. Other European countries do not fluoridate their water supplies for technical reasons. Many add fluoride to salt. In Ireland, we are encouraging people to reduce their salt intake for health reasons and the food industry to reduce the amount of salts in foods. It would not be attractive course for us to change to salt-based fluoride delivery system.

Professor O’Mullane

Deputy Twomey made some valid points on fluoride toothpaste. In 1989 the toothpaste industry agreed a code of practice about messages on toothpaste tubes. Several messages were adapted such as "use twice a day", "under seven year olds to be supervised by an adult", "use a pea-sized amount". The size of the messages should be increased. In a recent study we conducted, it appears these messages are not being adhered to by parents. Parents tend to allow too much toothpaste to be used. The method for using fluoride toothpaste needs health promotion.

The advice of the expert body was based on much scientific evidence available concerning not brushing with fluoride toothpaste until the two years of age. The pattern of use of fluoride toothpaste is highly effective. However, the number of Irish people who use it effectively is low in comparison with the rest of Europe. If it is used incorrectly it can contribute to the level of fluorosis.

The information on the tube given by the expert body comprise the best available advice, based on the evidence that is available at the moment. The forum on water fluoridation spent a good deal of time debating this issue. The conclusion it came to is now being promoted and implemented by the expert body.

Deputy Twomey

The point is that nobody ever talks about this issue. We focus so much on the benefits or the risks from fluoride but it is obvious that a sub-group of young children is affected by fluorosis. As regards what Professor O'Mullane is saying, there are no public health campaigns about toothpaste. A dentist is never asked to examine a child for fluorosis, so all those issues concerning not using the amount of fluoride in toothpaste or limiting the amount being used, or even asking parents to check whether their children have fluorosis, are relevant. When Deputy Gormley presented his report here I actually went home and checked my children to see whether they had fluorosis.

Ms Queally

Did they have it?

Deputy Twomey

They did and I changed to non-fluoride toothpaste.

Professor O’Mullane

Had they cavities?

Deputy Twomey

There were no cavities. They did not eat sweets, either.

Professor O’Mullane

That is the benefit and the risk, which is also an issue here. Certainly the fact that the Deputy's children had no dental decay is a very important point. If fluoride is used appropriately and correctly, there is a tremendous benefit. However, as regards fluoride toothpaste, the forum made its recommendations on the best available evidence. Some of this is now on the toothpaste tubes and being promoted.

Ms Queally

The Dental Health Foundation has produced a number of programmes for young children and their parents. A number of resources are available for dentists, in dental surgeries and also through professionals such as public health nurses, as well as, hopefully, in GP surgeries.

Deputy Twomey

Not yet.

Ms Queally

Another initiative is a schools campaign such as the Winning Smiles programme, which has been positively evaluated. That type of public education takes time, however, but slowly and surely the message hopefully gets across in terms of the amount of toothpaste to be used. Toothpaste advertisements, generally, show a big stripe across the toothbrush, so that is the type of message one is battling against — in terms of getting the pea-sized amount onto the toothbrush and brushing regularly.

A number of programmes have been positively evaluated, however, and are being implemented in schools and with practitioners such as public health nurses and, hopefully, GP and dental surgeries as well.

Deputy Twomey

We have to undergo a good deal of education yet.

Mr. McDermott

The fact that the Deputy actually went home and checked whether his children had fluorosis says a great deal about the seriousness of the problem. If it was a problem I believe he would have known about it without having to check.

Deputy Twomey

Sometimes parents do not know about it and regard staining on a child's teeth as something over which they have not much control, especially when dealing with baby teeth. Parents generally do not go to much trouble as regards examining and knowing what to look for. That is why I am saying we might miss the point by placing too much emphasis on just using fluoride to sort out our problems.

I appreciate the professor knows there are a great many children with serious problems as regards dental caries, although living in fluoridated areas. Therefore, there are significant problems which are not being dealt with. Perhaps we are taking too much comfort from the fact of the water being fluoridated and placing insufficient emphasis on sugar intake and the proper brushing of teeth.

Ms Queally

Certainly in the action plan that has been produced, the emphasis is on a strong communication and promotion campaign. No member of the expert group would argue that this should run in parallel. It is not an either-or situation. Ideally, one should like to reach the point where health behaviours were such that it would not be necessary.

Deputy Twomey

As a GP, I have seen children under ten with three to five caries. This is simply unacceptable.

Ms Queally

As Professor O'Mullane said, Ireland has one of the highest readings in Europe as regards the consumption of fizzy drinks. That will do it, despite the best efforts.

Deputy F. O’Malley

I want to follow on from that because it strikes me that the size of the toothbrush will indicate how much paste may be used. Perhaps we should try to encourage people to use smaller toothbrushes. Would the expert group say that the Irish public is more at risk from toothpaste use than fluoride in the water, since that is well monitored?

I shall put my remaining questions because I know we are moving on. The difference in the levels of dental decay between the North of Ireland and the South is significant. That speaks volumes about the benefit to be derived from fluoride. If fluoride was withdrawn from water, what would be the consequences? I do not believe this has been discussed. It is seen as having no impact and given the difference between the North and South, clearly there are some risks and that is why I am asking whether the withdrawal of fluoride is a no-risk option.

As Dr. O'Hickey said, in a situation such as this, it is a matter of public policy, but politicians and the Minister, in particular, must be guided by advice. Irrefutable advice will come from the WHO, which is clearly in favour of fluoridation. Would the group not agree? That is the type of advice that we, who are not experts, must cling to.

I attended a hygienist earlier this week and I took the opportunity to ask her about the question of fluoride in water. She was aged 41 and had grown up in Castlebar in an area where there was no fluoride in the water. She said the incidence of dental caries was enormously significant when she was growing up compared with now. I found that very interesting, coming from a professional who is constantly assessing the dental health of patients. This brought home to me the impact and it was confirmed when Dr. O'Herlihy mentioned that somebody had said fluoridation of the water in Ireland was among the ten most beneficial general health measures that could be taken. Such an assertion is not insignificant.

I want to refer back to a question put by Deputy Connolly about the toxicologist. I am not sure whether he got the complete answer as I was out of the room for a short while. Presumably if someone puts a chemical into a general water supply it must be approved by a toxicologist or a technical chemical expert responsible for advising about levels.

Would the expert group be inclined to introduce fluoridation if it was not there already?

Senator Henry

I am conscious that I am late for the presentation, but I was on an act of corporate mercy. Like Deputy Fiona O'Malley I am particularly interested in the difference in the levels of dental caries between the two jurisdictions in Ireland. Perhaps it has been said already, but have any moves been made to introduce fluoride into the water in Northern Ireland, since Dr. O'Herlihy was saying they were trying to increase levels in the rest of the United Kingdom?

Dr. O’Herlihy

Is the Senator talking about Northern Ireland specifically?

Senator Henry

I thought I heard Dr. O'Herlihy say they were trying to introduce it in other parts of the United Kingdom. Is Northern Ireland one of the parts where they are hoping to introduce it?

Dr. O’Herlihy

All I can say is that I was talking to the chief medical officer for Northern Ireland last week and he is certainly in favour of introducing it. However, under UK legislation there are certain steps to be taken before it can be introduced. There are political issues in Northern Ireland that would make it more difficult to introduce compared with some other parts of the United Kingdom. His wish would be to move forward with it, however, because of the significant benefits.

If fluoride was withdrawn from the water there is no doubt that there would be an increase in caries levels over time. It would increase to a higher level than in Northern Ireland because dental hygiene is not as good in Ireland as it is in many other countries, which was shown in a recent survey, and because of excessive intake of the wrong type of foods such as sweets and sweet drinks. If fluoride is taken out of the water, the burden will fall on the most disadvantaged in society.

The World Health Organisation, the Centre for Disease Control and Prevention in Atlanta, the US Surgeon General, the World Dental Federation, the International Association for Dental Research, the faculty of public health of the Royal College of Physicians of Ireland and the Association of Public Health Practitioners in the UK all endorse water fluoridation. More than 350 million people worldwide are drinking artificially fluoridated water and another 100 million drink naturally fluoridated water, and there have been no harmful effects. If we had not fluoridated our water in Ireland, we would be in the position of the UK, where they are seriously thinking of introducing it.

Dr. O’Hickey

Deputy O'Malley asked what would happen if water fluoridation ceased here. Two examples occurred in Scotland and in Holyhead in Wales. The water in Holyhead was fluoridated for many years, but a decision was taken to discontinue those schemes after the privatisation of the water supplies in the UK. Someone said to me recently in the UK that if one was to set up such an experiment to see what would happen, it would not be allowed on ethical grounds, yet that is what happened there. Of course, what happened was that the situation returned to the status quo ante.

Deputy F. O’Malley

What about my question on the toxicologist?

Dr. O’Hickey

We should not tell tales out of court, but we have been seeking a toxicologist from the very beginning. A toxicologist was appointed to the expert body, but at that time toxicologists and other medical consultants were in dispute with the Department of Health and Children on an unrelated matter. As a matter of principle, some of them would not take up these positions, so it was left vacant. We asked the Department on several occasions to supply a toxicologist, or even to suggest one, but we are still waiting.

Deputy F. O’Malley

Does that mean that water is being added to the system without fluoride? What expert is overseeing this?

Dr. O’Hickey

The controls are in place on the daily and monthly testing of the water. The monthly testing is critical because it goes to the public analyst as it must be an independent test under the legislation. That is done by chemical methods in a laboratory. It is very precise and a more than adequate control.

Deputy F. O’Malley

Are the witnesses satisfied that a suitably qualified person is doing it?

Dr. O’Herlihy

Yes.

Dr. O’Hickey

The reports on every single water supply in the country are regularly sent to the HSE, which then transmits them to the Department of Health on a monthly basis.

Senator Browne

I am more confused than ever. This boils down to a simple issue of mass medication. Unfortunately, we are not giving people a choice. It is crazy that the situation is not being monitored from a health point of view in the long term. It is a different world today than in the 1950s. There have been huge advances now in dental hygiene. We now have fluoride in toothpaste, whereas we did not have it in the 1950s. Therefore, we have a way of controlling it. There is no health campaign, although one is needed. I used to teach before I entered the Oireachtas and I knew nothing about this until recently. Deputy Twomey also knew nothing about it, even though he is a doctor.

There are question marks over the infant formula that are causing concern, as people cannot choose it. Many people around the country are in group water schemes that do not have fluoride, yet they have quite good teeth. Many people in the countryside have wells where the water contains no fluoride, yet they have excellent teeth. Are we comparing like with like? If a child in a fluoridated area drinks fizzy drinks, eats sweets and does not wash his teeth, he will have bad teeth irrespective of the condition of the water. I am very cautious about comparing ourselves with Northern Ireland. I would love to see a proper study being carried out, in which we could compare people with roughly the same eating habits and the same sugar intake. If one washes one's teeth regularly, uses proper toothpaste and avoids sweets, one will avoid the need for fillings.

Do the witnesses accept that some people have a bad reaction to fluoride? I know of people who put filter systems into their houses. One lady contacted me who was suffering from ME. When a filter system was put into her house, many of her problems disappeared.

The confidence of the witnesses in local authorities is amazing. I can safely say that I have no confidence in those authorities to monitor anything, as most of them cannot even return a phone call.

Chairman

The Senator should be fair now.

Senator Browne

Does the Chairman accept that they do not return phone calls?

Chairman

There is a big difference between that and the debate today.

Senator Browne

The director of services in Carlow County Council admitted the other day that half of the water supply was leaking out of the system. There is currently no water in some parts of Carlow town. There was an outbreak of cryptosperidium two years ago in Carlow and there was another outbreak recently in Ennis and in Monaghan. The water system is creaking all over the country. The local authorities have been inept in monitoring the water systems. We have an aging water system in place. There are leaks everywhere and if the water is getting out, other things are getting in.

Chairman

That does not tie in to what we are talking about here.

Senator Browne

It does tie in. The witnesses are putting emphasis on having confidence in the local authorities, but I do not have such a confidence. I reported water shortages two years ago to officials at my local authority and they tried to convince me that it was not happening. However, when I turned on the tap there was no water. I have problems with local authorities managing water and the aspect of mass medication to which I referred earlier.

Dr. O’Hickey

The local authorities do not test the water. Employees of county councils check the water supply on a daily basis, but that is just a fairly course colorimetric method. A sample is taken out of the water and is compared with a standardised, coloured sample. However, in the statutory test, the water must be taken from designated points along the distribution system in every water supply. That is sent the public analyst in Galway, Cork or Dublin. These people are not employed by the HSE or the Department of Health and Children. The tests are done on a routine monthly basis. There are so many stacks, they get bored looking at them.

Senator Browne

The samples are taken——

Dr. O’Hickey

One was taken in Dame Street, for example.

Senator Browne

Considering the water system from the reservoir to the house, where are the samples taken?

Mr. McDermott

They are taken at locations chosen at random throughout the system.

Senator Browne

Are they taken in houses?

Mr. McDermott

Some are. The samples come back to us with the report which notes where they are taken. Having examined some of them, I know some are taken in pubs, crèches, private houses and schools — any place in the system that represents accurately the——

Dr. O’Hickey

It is not just one place in the system.

Mr. McDermott

No, they are taken throughout the system.

Senator Browne

Does Mr. McDermott accept there are major leaks in every water system in the country?

Mr. McDermott

That is probably correct but it does not have anything to do with——

Senator Browne

I wonder about water quality. If water is leaking, there is a possibility of contamination.

Mr. McDermott

The samples taken to verify the quality of water fluoridation are taken at end-user points throughout the system. While I accept there may be a possibility of contamination, that is not showing up in the tests we have seen with regard to water fluoridation.

Professor O’Mullane

I wish to answer some of the points made. The Senator stated people in non-private schemes in rural Ireland had better teeth. I am not aware of any study——

Senator Browne

I said they had perfectly good teeth without fluoridation.

Professor O’Mullane

I would like to see the evidence. Our data suggest that those who live in non-fluoridated communities have considerably worse levels of dental decay than those who reside in communities with water fluoridation.

An important point was made as to whether we were comparing like with like. In the case of the comparison between Northern Ireland and the Republic of Ireland, all the participants in the studies, in two age groups, were asked about their eating, dietary and toothbrushing habits and so on. A statistical technique called multiple regression was used to ensure all of these factors were taken into account. The level of dental decay in Northern Ireland was considerably worse, having taken account of the factors to which the Senator referred. That is the recommended method of taking into account other factors to ensure we compare like with like.

Deputy Fitzpatrick

When the level of fluoride in the water is lowered, will we continue to monitor the rate of DMFT?

Dr. O’Hickey

We have a sub-committee which is drawing up the parameters for such an exercise. It will consider two aspects. The structure will be the same as if it was a national survey. An area of the country will be selected from which a random sample will be drawn and studied. The sub-committee will examine the level of fluorosis and caries. It could be that there would be a fall in the level of protection if we were to drop the level of fluoride too far. We must keep an eye on this. The survey has moved beyond the consideration stage and we are about to implement it.

Deputy Gormley

I want to return to the question of health. Do the delegates agree that it is unacceptable that not a single health study has been carried out under section 6 of the original Act? Would the expert body not call for health studies to be carried out under that section?

Dr. O’Hickey

Section 6 of the Act is permissive. It allows the Minister for Health and Children, if he or she considers it necessary, to carry out a survey considering the health effects of fluoridation, which would include dental and other aspects of general health. This has been done in at least one instance of which I know, when a survey was carried out by research staff at University College, Cork. I ask Professor O'Mullane to expand on this.

Deputy Gormley

Is Dr. O'Hickey saying a study was carried out under section 6?

Dr. O’Hickey

Yes.

Deputy Gormley

I did not know that. It is news to me.

Professor O’Mullane

The 1989-90 study included a section dealing with the general health of the people.

Deputy Gormley

Was it carried out under section 6 of the Act?

Professor O’Mullane

I am not into Acts in a big way. All I know——

Deputy Gormley

Deputy Devins can laugh and find it extremely funny, but I am interested in the Act.

Deputy Devins

I thought the professor's reply was appropriate.

Professor O’Mullane

All I know is that the study was carried out and included as part of the national survey. It used a technique developed by the American Society of Anesthesiologists for categorising people into four grades of health. When that screening exercise was undertaken, no difference was found between those who resided in fluoridated communities. The same exercise was included in the national survey of adults' dental health conducted two years ago, the report on which will be published shortly. I had the opportunity yesterday to get one of our statistical colleagues to undertake a quick analysis which appears to show no difference. Also, in monitoring general health, Dr. O'Herlihy undertook an exercise recently to examine the level of——

Dr. O’Herlihy

The exercise examined the level of osteosarcoma between the Republic and Northern Ireland. There was no statistical difference between them. Having said that, it is a rare condition and the number of cases in Northern Ireland and the Republic is small. As we accumulate more statistics, we will keep an eye on the matter. However, we found no difference in the statistics we examined.

Deputy Gormley

When Dr. Hardy Limeback came before the committee, he quoted the York review with regard to the net benefit in respect of caries-free children. The net benefit in the York review was quoted as 14.6% between fluoridated and non-fluoridated areas. Does Professor O'Mullane accept that figure?

Professor O’Mullane

That was a net figure around which there were variations. The York review considered all the studies and came up with that figure. It is difficult to take it on board because if one considers the national surveys we have conducted, the percentage difference between the fluoridated and non-fluoridated groups differs with age. The figure of 14.6% is probably a little low. Our figures in monitoring water fluoridation are regarded as being well conducted, regular and monitored. Therefore, the net figure to which the Deputy asks me to react is a composite one from studies examined by the York review. I would have to combine figures for five, eight, 12 and 15 year olds. I suspect the figure is higher.

Deputy Gormley

How many of the expert body's studies were accepted by the York review?

Professor O’Mullane

The first comment made in the York review was that no randomised controlled clinical trials were being done and that it was impossible to do a randomised controlled clinical trial. In the case of the Republic of Ireland, when the Act was passed in 1960, it was decided to carry out a baseline study of the whole country, involving approximately 43,000 children. It was agreed at the time that for this study a legitimate time period within which to monitor the effectiveness of water fluoridation should be used.

The criteria included in the York review were different. It stated that if one introduced water fluoridation, one should perform one's baseline study at the same time. Consequently, our studies were not included. Deputy Gormley should note I do not agree with that decision.

Deputy Gormley

Very well. I accept that.

Professor O’Mullane

I have made known my views to that effect.

Deputy Gormley

I accept that. While this question has been raised before, obviously differences can be seen in respect of the oral health of children. However, the decayed, missing and filled teeth, DMFT, rates of adults are quite a different matter, as there does not appear to be a significant difference. I seek more information in this regard, as one does not see a major difference between adult populations in fluoridated and non-fluoridated areas.

Professor O’Mullane

I am surprised. We demonstrated a difference in the prevalence in the 1989-90 study. There are two ways to measure dental health in adults.

Deputy Gormley

Is Professor O'Mullane referring to DMFT rates?

Professor O’Mullane

One does not use DMFT for those who are more than 35 years old, because the "M", or "missing" component, is difficult to assess. One might examine an adult aged 35 who has a missing tooth. However, it could be missing due to dental decay, because it was removed for orthodontic reasons or for other reasons. In general, when measuring adult dental decay, one only talks about DMFT up to the age of 35 and we did demonstrate a difference in the case of DMFT.

The number of teeth present is the method of measuring dental health in adults.

Deputy Gormley

In respect of adults up to the age of 35, what differentials were found?

Professor O’Mullane

While I do not carry the figures around in my head, I am sure they are available somewhere. As I noted in respect of DMFT, the most reliable estimate of dental health among adults is the mean number of natural teeth present. This is generally regarded as the way to measure it. However, as I cannot recall the figures, I would be obliged to check them.

Deputy Gormley

Very well.

Professor O’Mullane

The other way of measuring adult dental health is to measure toothlessness, or edentulousness, that is, the number of people who have no natural teeth. This has dropped dramatically in Ireland in the past 30 or 40 years.

Deputy Gormley

Does Professor O'Mullane have figures for fluoridated and non-fluoridated areas in this respect?

Professor O’Mullane

While I cannot remember the exact figures, there is a difference.

Deputy Gormley

Unfortunately, I was obliged to leave the meeting briefly and in my absence someone made a comment. I caught the end of Dr. O'Herlihy's response which, if I understood him correctly, was to the effect that if we stopped water fluoridation, we would see a huge increase in dental caries.

Dr. O’Herlihy

While I stated that we would see an increase in dental caries, I do not recall using the word "huge".

Deputy Gormley

I will check the transcript of the meeting later. There is much evidence from many countries in which water fluoridation was stopped and no increase took place. Does Dr. O'Herlihy accept this?

Dr. O’Herlihy

All I can tell the Deputy is that it depends. I attended a conference last week at which a consultant from Anglesey referred to the fact that when fluoridation was stopped there, a significant rise in caries was detected. I understand that Dr. O'Hickey has already mentioned this. The consultant stated that anyone who wanted to see the effects of stopping fluoridation should perform a study in Anglesey.

Deputy Gormley

Does Dr. O'Herlihy accept that case studies exist from the former East Germany, Canada, Finland, Cuba and the state of Michigan in the United States, in which fluoridation was stopped and there was no increase? Such studies were referred to in the York review.

Dr. O’Hickey

Deputy Gormley may be referring to fluoridation schemes that were not national in scope. They were regional, or even local fluoridation schemes.

Deputy Gormley

As are many such schemes.

Dr. O’Hickey

Our scheme is different as it is a national scheme.

Deputy Gormley

Our scheme is unique in this regard.

Dr. O’Hickey

For instance, one can take the Netherlands as an example. As all these happened many years ago and there was no continuity. In the Netherlands, an experiment was set up to fulfil the criterion of a clinical trial. Two similarly sized cities, Tiel and Culemborg, were examined for ten to 15 years. The experiment was working extremely well until a political decision was taken by the Dutch Parliament to halt it. That was the end of the story and fluoridation was not continued anywhere else in the Netherlands.

The annual consumption in the Netherlands of fluoridated toothpaste is approximately 12 tubes per person per year.

Deputy Gormley

They do not consume it.

Dr. O’Hickey

This level of consumption differs greatly from ours. If we could replicate something like the Dutch experience, I would not have the slightest hesitation in dropping water fluoridation, if the substitution worked as well.

Deputy Gormley

I put it to Dr. O'Hickey that we have examples such as Chemnitz in the former East Germany and Kuopio in Finland. While I will not go through them all, clear examples exist in which water fluoridation was stopped and dental caries did not increase.

Professor O’Mullane

I am particularly familiar with the reports pertaining to Kuopio and the example from East Germany. Certainly, there are studies that will show that this happened. I am sure Deputy Gormley has studied the article in respect of Kuopio, as have I. It makes the point that the number of preventative strategies differs completely from what happens here. In other words, on the basis of the issue we raised earlier about sweet-eating and tooth-brushing habits, Dr. O'Herlihy's suggestion is correct.

Certainly, when one compares the Republic of Ireland to Northern Ireland, having carried out the logistic statistical analysis to ensure that one compares like with like, all the evidence is that the level of dental decay would increase to the levels that obtain in Northern Ireland. This is the only extrapolation one can make. In the case of Kuopio, this is dealt with at great length by Professor Hausen in his article. Incidentally, he also appeared before the forum on water fluoridation and made the same point.

Deputy Gormley

I will revert to the study by Steven Levy. If I understood the witnesses' earlier replies correctly, they suggested that Dr. Levy now has a different point of view. I seek clarity in this regard.

The Food Safety Authority of Ireland, FSAI, study to which Professor O'Mullane referred stated that if one consumes fluoridated water in the first year, there would be no difference in terms of fluorosis of the permanent dentition. Is that not correct? Did the FSAI study not say this?

Professor O’Mullane

What is the question?

Deputy Gormley

I suggested the FSAI study, to which Professor O'Mullane referred, found there would be no difference in terms of fluorosis of the permanent dentition, if one consumed fluoridated water in the first year.

Professor O’Mullane

As opposed to if one did not. Is that it?

Deputy Gormley

Yes. There was no difference. Is that not correct?

Professor O’Mullane

I am unsure whether the report said that. I do not have the paper to hand.

Deputy Gormley

I have it to hand. However, I understand this is what Professor O'Mullane has stated — it is certainly what Dr. O'Hickey stated — in their briefing to the joint committee. I seek clarity on this point because the argument is based on the assumption that the first year of life poses no risk of fluorosis on the permanent teeth. The FSAI study's assumptions were based on this point.

I revert to the Levy study, which shows this is not true. While I am open to correction in this regard, the Levy study investigated the first four years of life and stated that they pose the greatest risk of fluorosis on the permanent upper front two teeth. In performing his analysis — again the witnesses may correct me if I am wrong in respect of any of this — Steven Levy found that exposure during the first year of life poses a greater risk of fluorosis than is the case in the second, third or fourth years. Is that correct?

Professor O’Mullane

Did he say that about permanent teeth?

Deputy Gormley

He said that about the permanent upper front two teeth and I have the article here.

Professor O’Mullane

I would need to read the article again. I do not have it with me so there is a slight difficulty.

Chairman

Could Deputy Gormley read the relevant section?

Deputy Gormley

That is the relevant section, from which I will take a direct quote, if the Chairman wishes. According to the article, "fluoride intakes during each of the first 4 years were individually significantly related to fluorosis on maxillary central incisors, with the first year most important (P < 0.01), followed by the second(P < 0.01), third (P < 0.01), and fourth year(P = 0.03)."

Professor O’Mullane

How does that link with Dr. Anderson's——

Deputy Gormley

Dr. Anderson found it had no significance in respect of fluorosis of the permanent teeth.

Professor O’Mullane

We are mixing up two things. The first year is important in respect of actual infant feeding formula practices here. The entire article concerned the first year.

Deputy Gormley

Dr. Anderson did not state that it was significant in terms of the permanent teeth. He was talking about the first teeth. Dr. Levy states that it affects the fluorosis on the permanent teeth. Is he correct in saying that? This is all I am trying to get at here.

Dr. O’Hickey

If I may interrupt, Deputy Gormley mentioned maxillary central incisors.

Deputy Gormley

That is what it says here.

Dr. O’Hickey

Does it say permanent maxillary incisors?

Deputy Gormley

It says "on the permanent upper front two teeth".

Professor O’Mullane

I cannot see the link in the estimate published by Dr. Anderson. For instance, all the children in the study we are carrying out in Cork on infant feeding formula are in their first year. The entire question of infant formula concerns the first year. The first year is important.

Deputy Gormley

Steven Levy has conducted these studies in Iowa for many years.

Professor O’Mullane

Yes. What Dr. Anderson said was that the estimate of the amount of fluoride taken in was at a level that, on the basis of the international data at the time when one was talking about between 0.4 ppm and 0.7 ppm, the likelihood of it creating any problem with regard to fluorosis in permanent teeth at a level greater than very mild was low.

Deputy Gormley

He said there was a low risk of moderate fluorosis. Is that what he said?

Professor O’Mullane

He would not be using the categorisation——

Deputy Gormley

In the abstract I saw, he said there was a low risk of moderate fluorosis.

Professor O’Mullane

In other words, the categorisation I presented to this committee was normal, very mild, mild, moderate and severe. When we come to moderate, which is very rare in Ireland at the moment and which is what Dr. Anderson was saying, I cannot see the link between what Deputy Gormley is saying in respect of——

Deputy Gormley

The Levy study is very clear that in terms of fluorosis and permanent teeth, the first year is of most significance. This is why I brought up the article by Professor O'Mullane's colleague on the expert body, Professor Clarkson, who has said that fluoridated water should not be used to reconstitute infant formula. I have read numerous studies which say the same thing, which is why I am pursuing this line of inquiry because, frankly, it is the expert body's Achilles heel. It is the one thing on which it is very weak.

Deputy Devins

In fairness to the expert body, Deputy Gormley obviously has articles in his possession. I suggest that he gives the references to the expert body, which could study them and come back and tell us what it thinks about them. Quoting an article which members of the expert body do not have in front of them is very unfair.

Deputy Gormley

With respect, this is why I asked whether they were acquainted with Steven Levy and whether he was over here in September. I took it that they knew his work inside out.

Deputy Devins

I do not know the man but he may have published thousands of articles. I am only trying to help the situation. It is only fair to the expert body.

Dr. O’Hickey

We are not unwilling to accede to the Deputy's request.

Chairman

We will not move on if we refer to articles the expert body has not seen. If the Deputy is prepared to come back another day, we can do so because clearly we will not——

Deputy Gormley

They can send me an e-mail.

Chairman

If the Deputy had the references, he could talk to them.

Deputy Gormley

There are people, some of whom have been referred to already, who would take a contrary view, such as Dr. Hardy Limeback who has done extensive work on this, who, I believe, came before the fluoridation forum and who also clearly recommended in front of this committee that fluoridated water should not be used to reconstitute baby formula. This was his clear recommendation. If people who advocate fluoridation are going to make comments, those who have an opposing view should also have an opportunity to make comments.

Chairman

We have no problem with that.

Mr. McDermott

My point is perhaps not directed exactly at the Deputy's point. In regard to the reconstitution of infant formula, there is a concern that people who hear this message may take it that they should use bottled, that is, non-fluoridated, water to reconstitute it. We know the use of bottled water to reconstitute infant formula poses a significant risk to small babies because it mostly contains high levels of sodium which could be toxic to the kidneys and pose serious risks.

Deputy Gormley

We have never recommended that.

Mr. McDermott

I am not saying the Deputy has recommended it, but it is important that this is also stated at this point.

Professor O’Mullane

I wish to make another point given that Deputy Gormley raised the question of infant formula. During the course of the forum on water fluoridation, this issue came up and was discussed at length. A particular issue arose in respect of the use of fluoridated water to reconstitute infant formula. In the initial assessment done by Dr. Anderson, it was assumed that all the fluoride in the water would be available to be absorbed.

We did a study and looked at the amount of fluoride available following reconstitution with infant formula and found that there was quite a reduction. Apparently, there are two kinds of infant formula. One formula is used for the first six months of life and one then changes to a different formula later on. There was quite a reduction in the amount of fluoride available, particularly in respect of the formula used from six months onwards. I am still slightly confused about the actual linking between what Dr. Levy said and infant formula but am quite happy to look again at it and see what is going on. Essentially, there was a reduction in the amount of fluoride available, which is an important point to remember. If one assumes that——

Deputy Gormley

I will tell Professor O'Mullane why I am bringing it up. On page 252 of the forum on fluoridation's report, it clearly states that, "on balance the Scientific Committee has taken the view that the most critical period for developing dental fluorosis of the permanent central incisors is between 15 and 30 months". This is what the forum came up with. I am saying that with his latest study, Dr. Levy says it is not 15 to 30 months rather it is the first year when infants are consuming formula. It is as simple as that. Is this sufficiently clear?

Professor O’Mullane

I would like to study Dr. Levy's paper.

Chairman

We have again returned to this position. To be fair, the expert body must be given this opportunity.

Ms Queally

I know the first year is very early, but, for example, in the latter half of the first year, one may have the eruption of some of the first teeth after six or seven months. Obviously, we would not recommend that children on these early teeth use fluoride toothpaste, which could be ingested.

Deputy Gormley

Seán McEntee was mentioned. If one goes back over the debates in the Dáil, it is quite clear that Mr. McEntee and a number of his colleagues believed that fluoride needed to be ingested. Is it not the case that we now know and all agree that fluoride works topically, not systemically, and does not need to be ingested? Is this not the case?

Dr. O’Hickey

The effect is topical. There is a small residual systemic effect, but fluoride must be in other bodily fluids for saliva, plaque and the oral environment in general to be saturated with sufficient fluoride ions. To get the topical effect, one would need to reinforce the amount of saliva in one's mouth constantly.

Deputy Gormley

The topical effect is achieved by using fluoridated toothpaste. Is that correct?

Dr. O’Hickey

Yes.

Deputy Gormley

Mr. McDermott stated that there was a reduction in dental caries prior to the introduction of fluoridated toothpaste. Can Dr. O'Hickey quantify that reduction?

Dr. O’Hickey

Not now, but we have the figures to answer the question.

Deputy Gormley

Would Dr. O'Hickey agree that according to European studies, fluoridated toothpaste has had a greater impact on oral health than water fluoridation?

Dr. O’Hickey

Certainly, where it has been used optimally. There is no argument on that point.

Deputy Gormley

We are using fluoride toothpaste and fluoridated water supplies. On that basis, one would expect us to have excellent oral health, but we are down the league tables significantly whereas countries that do not fluoridate their water are above us.

Professor O’Mullane

This is where the study comparing Northern Ireland and the Republic of Ireland is important. On the question of whether water fluoridation has an additive effect to the use of fluoride toothpaste, the answer is "Yes" according to the study. Fluoridated toothpaste was introduced to Northern Ireland and the Republic of Ireland at approximately the same time in the early 1970s and the patterns of use are similar, although people in Northern Ireland use slightly more.

The benefit of the combined effect of water fluoridation and fluoride toothpaste would appear to be of sufficient merit to support the figures quoted in the study. There is a substantial difference in the level of dental decay between here and the North. Taking everything else into account, such as sweet-eating and tooth-brushing habits, the study appears to suggest that the level of dental decay is considerably lower in the Republic of Ireland than in Northern Ireland. It also suggests that fluoride toothpaste has an additive effect to water fluoridation and vice versa.

Deputy Gormley

The warnings on fluoridated toothpaste are more explicit in the United States of America. Would our guests' committee welcome explicit warnings on toothpaste in Ireland so that there would be no doubt in parents' minds?

Dr. O’Hickey

That is a requirement placed by the Food and Drug Administration in the US.

Deputy Gormley

Would Dr. O'Hickey not agree that similar warnings should exist here?

Ms Queally

We would like to see more warnings and information on packaging.

Dr. O’Hickey

And in larger type.

Deputy Gormley

That is what I mean.

Professor O’Mullane

Other techniques can be used, such as applying the stream of toothpaste crossways instead of longitudinally, that is, across the brush's width rather than along its length.

Deputy Gormley

Is advertising that shows big swirls of toothpaste a problem?

Professor O’Mullane

That is what I mean. The advertising could be clearer, which is a recommendation in the forum report. We are engaging with industry on these matters.

Deputy Gormley

Are our guests disappointed with the significant delay in implementing their report? The report is dated 2002, but one of the recommendations was only implemented yesterday.

Mr. McDermott

I would have preferred it to happen more quickly. Given the necessary amount of preparatory work in terms of equipping the Department of Health and Children with the background information and comparative work, five years is not too disappointing. While I am slightly disappointed, I am not surprised.

Dr. O’Hickey

There are other factors. As the Deputy knows, the health services were revamped, the HSE was appointed and the Department was reduced in importance. That people moved around within the Department meant a lack of continuity. Often, a great deal of time was needed to brief the new occupant of a post on this complicated topic. As my colleague stated, we would have preferred a faster implementation.

Chairman

I thank our guests for appearing before the committee for almost three hours.

The joint committee went into private session at 11.55 a.m. and adjourned at 12.30 p.m. until 9.30 a.m. on Thursday, 15 February 2007.