The task we were set was to determine whether fluoridation had benefited oral health, whether it posed any risk to general health, and to make a series of recommendations on our findings. The conclusions we drew were that fluoridation has certainly been effective in reducing dental decay in Ireland in children, adults and also the elderly as a specific group because of a specific condition that affects the elderly called root caries.
We found no evidence that health is adversely affected. The balance of evidence is certainly that there are no negative health affects in water fluoridated at one part per million or less. However, we found that while dental sclerosis rates are low in Ireland, they have been increasing since the 1980s. That indicates that people are getting more fluoride from sources other than fluoridated water than they were in the past.
Two members of the forum took separates views to the forum and their views are in the forum's report as well. The Consumers Association of Ireland had a member on the forum; it opposed fluoridation on the question of personal choice. The Irish Doctors' Environmental Association also took a neutral stance on the benefits and negative possibilities of fluoridation but also opposed the continuation of water fluoridation on the question of choice and the philosophy of that particular organisation.
Our recommendations are based on eight specific areas. There are four main recommendations on policy aspects, first, that water fluoridation should continue as a public health measure. However, a reappraisal of the data in the modern setting since the introduction of fluoridated toothpaste, indicates that we can now fluoridate water at a lower level than was previously necessary. We recommend this level to be between 0.6 and 0.8 as opposed to the previous level of 0.8 to 1.0.
We recommend amendments to the fluoridation of water supplies regulation to reflect these changes and to reflect changes in technologies, and also the setting up of an expert body to continue monitoring and surveillance of this area.
The second set of recommendations were on technical, engineering aspects which concern the fluoridation plant. There is quite a deal of detail in there concerning all plants, and about communication of results of fluoridation tests to the public, monitoring of the actual fluoridation agent and so on.
As regards recommendation three, on fluoride toothpaste, the evidence before us indicated that the main source of this extra fluoride that people are getting nowadays was from inappropriate swallowing of fluoridated toothpaste. Such toothpaste is fluoridated at over 1,000 times the concentration of fluoridated water, so a small amount of fluoridated toothpaste swallowed will raise a reasonably high level of fluoride in the body. The evidence is that we should continue to use fluoridated toothpaste because there is an additive benefit.
Fluoridated toothpaste and fluoridated water seem to work in different ways. When used together, one gets the best benefit. However, there are two conditions to that. Because decay levels are very low in Ireland decay risk for children under two years of age is very small. Therefore, we recommend that they do not need to use fluoridated toothpaste. Also, such children's swallowing reflex is not very good so they can swallow inappropriately. Because of the low risk and the risk of staining teeth, we recommend they do not use fluoridated toothpaste - they should simply brush their teeth with a toothbrush and water. However, if the decay risk is high then the advice changes. A professional can advise a person to use fluoridated toothpaste.
For children between the ages of two and seven, the risk of staining is still present but the decay risk is much higher. Therefore, we recommend the use of fluoridated toothpaste using a pea-sized amount of toothpaste on the brush. There are photographs of this in the forum report. As a rule of thumb, instead of putting toothpaste on the brush lengthways as one sees in the television advertisements, one should put it breadthways, which will provide approximately the correct amount. We do not recommend low fluoride toothpaste because there is not really any great evidence that it is effective in preventing tooth decay.
The fourth set of recommendations are on the oral health care industry and concern clear labelling of fluoride products, clear instructions on the use of the products and also child resistant closures on some fluoride products, such as mouth rinses. The concern there is primarily to do with other things that are in these rinses, including alcohol.
The fifth set of recommendations is on infant formula. There is an extensive appendix in the report dealing with this issue, which is a report by the Food Safety Authority. We recommend to continue constituting infant formula as before, with boiled tap water. We do not recommend the use of bottled water because there are other constituents in normal bottled water that are not good for children, particularly high sodium levels. Some bottled waters on the market are suitable and these tend to be French manufactured waters. For instance, where people are on group water schemes and there are high levels of nitrates in the water, certainly these bottled waters are suitable but this would be on professional advice. The general recommendation is simply to use tap water.
Recommendation six on fluoride research is to ensure that, as a matter of course, the fluoride research that is currently ongoing continues, that information on general health is also included, along with dental health, in future surveys, and that the expert body itself will prioritise research in this area.
Recommendation seven is on information and public perception. It is basically about getting the message to the public. One of the things that came across quite strongly in the public consultation was that there was a great deal of confusion as to what fluoridation was all about.
The eighth set of recommendations is on public health and professional practice which is concerned about getting the right information to professionals so that they will have the right information to give their clients.
In terms of disseminating the report and public participation, we have made presentations at a number of county councils, various professional bodies, health boards, the Irish Society for Toxicology, the Irish Society for Dentistry for Children, and local authority staff. We have been on local and national radio programmes to try to get the main information out. In addition, the Dental Health Foundation has also produced some very good information leaflets and posters for use in dental clinics on this topic.