Alex White (Dublin South, Labour) | Oireachtas source

I welcome the opportunity to address Members to set out in the strongest terms the reasons this Bill which would provide no benefit for the public and be likely to result in deterioration in the oral health and, therefore, general health of the population should be opposed. Deputy Brian Stanley’s Bill proposes that the Health (Fluoridation of Water Supplies) Act 1960 be repealed in full and that it be an offence for a body corporate or certain officers of a body corporate to add fluoride to water. Given the importance of water fluoridation as a public health measure, I cannot support the Bill.

Deputy Brian Stanley claims that water fluoridation is unsafe, that there are huge health questions surrounding it and that the weight of scientific evidence is against it. Nothing could be further from the truth. The balance of scientific evidence worldwide confirms that water fluoridation, at the optimal level, does not cause ill effects and protects the oral health of the population. Water fluoridation is the adjustment of the natural concentration of fluoride in drinking water to the optimal recommended level for the prevention of dental decay. Fluoride is a natural mineral found in soil, fresh water, sea water, plants and many foods.

Fluoridation began in Ireland in 1964 on foot of the Health (Fluoridation of Water Supplies) Act 1960. The Act provides that the health authorities arrange for the fluoridation of public piped water supplies and that local authorities act as agents for the health authorities in providing, installing and maintaining equipment for fluoridation, in adding the fluoride to water and testing the fluoride content of water to which fluoride has been added. These functions are provided for in the Fluoridation of Water Supplies Regulations 2007 which revoke previous fluoridation regulations. The constitutionality of the Act was challenged in the High Court in 1963, as adverted to by Deputy Brian Stanley, and in the Supreme Court, on appeal, in 1964. In July 1964 the decision of the Supreme Court confirmed the constitutionality of the fluoridation Act.

Approximately 68% of the population receive fluoridated public water supplies. The legislation on water fluoridation requires a daily test to be carried out at water treatment plants by the local authority water services staff. Monthly fluoride testing is carried out by the HSE. The Environmental Protection Agency also carries out testing which requires monitoring of fluoride levels in water supplies. If the fluoride levels are found to be outside the range specified in the legislation, those responsible are notified, prompt adjustments are made to the dosing equipment and a new test is carried out. The Environmental Protection Agency’s 2011 report, The Provision and Quality of Drinking Water in Ireland, indicates that 98.8% of samples from public water supplies and 98.9% of samples from public group water schemes were in compliance with the legislative requirements.

A code of practice is in place to ensure the proper implementation, by all personnel involved, of the procedures for the fluoridation of the public water supplies to the prescribed standards, in order to minimise the risk of injury or damage to plant, personnel and the environment.

It has been claimed, although not by Deputy Stanley, that fluoride used in Ireland is "a by-product of the fertiliser industry". This is not true. While a fluoride ion is a fluoride ion no matter where it comes from, the fluoride currently used for water fluoridation is sourced as a primary product. It is mined directly as a raw material in the form of the mineral fluorospar, which consists of calcium fluoride. It then goes through a purification process to conform to tightly controlled specifications to produce hydrofluorosilicic acid. Some fluoridated public water supplies have background levels of naturally occurring fluoride. These levels are augmented using the acid to the prescribed optimal level.

At present, the level of fluoride in drinking water is in the range of 0.6 to 0.8 parts per million. A higher level of 0.8 parts to 1 part per million was applied until 2007. Parts per million is equivalent to milligrams per litre. The level was reduced to take into account both international and Irish research on fluorosis occurrence and the increased availability of fluoride to the population from other sources. It is worth noting that EU law defines a maximum permitted concentration of 1.5 parts per million for public water supplies through its drinking water directives. The Irish levels are set at approximately half that permitted by EU legislation.

The Irish Expert Body on Fluorides and Health, established in 2004, advises on fluoride safety and related issues. The expert body and its sub-committees have broad representation from areas such as dentistry, toxicology, biochemistry, environmental health and public health medicine. Safety is determined from the available scientific evidence. In evaluating ongoing research, the expert body accepts the standard and fundamental scientific principle that any single piece of scientific evidence by itself remains hypothetical unless it can be repeated or confirmed by other scientists. Therefore, it considers scientific evidence that has been submitted to examination by other scientists, usually by publication in recognised peer-reviewed scientific journals, after such publication has been approved by independent referees. This ensures that the advice provided by the expert body is impartial and evidence-based.

Studies conducted internationally have consistently indicated that water fluoridation is safe and effective in preventing dental decay in both children and adults. It is the most efficient way to prevent one of the most common childhood diseases, tooth decay. Comprehensive reviews have been conducted in many countries. Reviews from the United Kingdom include the York review of 2000 and the review by the Medical Research Council in 2002. There have also been more recent reviews in Australia in 2007, Canada in 2010 and, most recently, the European Union in 2011. None of these reports has established any basis for considering that fluoridated water at an optimal level poses any systemic health risks.

The question is sometimes raised about the need to drink fluoridated water if fluoridated toothpaste is used. Fluoride in water works directly on the tooth surface. It also works indirectly via the saliva, so it has a double effect. There is also a pre-eruptive protective effect from fluoride working indirectly. Toothpaste works directly on the tooth surface only.

The national survey of children’s oral health in 1984 found that lifetime residents of fluoridated communities had substantially lower levels of dental decay than lifetime residents of non-fluoridated areas. Eighteen years later, in the North South Study of Children’s Oral Health 2002, again it was found that levels of dental decay were substantially lower in lifetime residents of communities living in fluoridated-water areas. These studies clearly show the benefits of water fluoridation in Ireland since its introduction.

Contrary to what has been claimed, the North South Survey of Children’s Oral Health in 2002 demonstrated substantial benefits of fluoridation in the Republic of Ireland compared to Northern Ireland, whose water is not fluoridated. There are ongoing oral health promotion and healthy eating campaigns in both jurisdictions. Fluoridated toothpastes are also widely available in both areas. Nevertheless, there continues to be a clear benefit from water fluoridation.

The North-South survey found that of those living in areas with fluoridated water, more than one in three children, or 37%, have dental decay by the age of five. In areas where there is no fluoride in the water, over half, or 55%, of all five-year-olds have experienced dental decay. The study entitled Oral Health of Irish Adults 2000-2002 showed decay scores were lower among fluoridated groups for all age groups and particularly in the 35-44 age group.

The forum on fluoridation, which reported in 2002 and which had senior representation from a broad range of relevant sciences, found there was no evidence at that time of any negative health effects, stating that "The best available and most reliable scientific evidence indicates that, at the maximum permitted level of fluoride in drinking water at 1 part per million, human health is not adversely affected". As I have stated, the level of fluoride in drinking water in Ireland was reduced to between 0.6 and 0.8 parts per million in 2007.

There are five categories of dental fluorosis, ranging from very mild to severe. The two lowest levels are mild and very mild and are only detectable by a dentist as faint white flecks on the surface of teeth. There are no known side effects of optimal water fluoridation other than mild dental fluorosis, a cosmetic or aesthetic condition that refers to the way teeth look. It is not considered to be an adverse health effect. At the levels at which fluoride is present in Ireland's water supplies, any occurrence of dental fluorosis is very mild or mild. Not all enamel defects are caused by drinking fluoridated water. In the majority of cases, dental fluorosis generally does not require any treatment. This is in contrast to the treatment of tooth decay, which may on occasion involve the use of general anaesthesia and hospitalisation. Furthermore, non-treatment of dental fluorosis has no health consequences, whereas non-treatment of tooth decay can lead to pain, trauma, disfigurement, loss of teeth and function, problems with nutrition and growth, work or school absenteeism and a significant financial and social cost.

Sometimes the risk of dental fluorosis is wrongly equated with health risk. The American Dental Association issued a letter in 2007 stating its concern that some opponents of water fluoridation may have been mischaracterising its report Interim Guidance on Fluoride Intake for Infants and Young Children to mean that fluoridated water should not be used to mix infant formula. The association’s advice is that using fluoridated water is safe. The Food Safety Authority of Ireland and the expert body also advise that there is no significant evidence of any adverse effects to the health of infants from consuming infant formula made up with fluoridated tap water. Fluoride concentrations in Irish tap water pose no known medical problems either for infants or for the population in general.

Contrary to what was suggested by Deputy Stanley, the Department of Health has rigorously monitored dental fluorosis and responded to evidence of a change in fluorosis levels. The 2002 study on children’s oral health showed an increase in the levels of enamel fluorosis over what had been detected in the 1984 study. Since the levels of fluoride in water had not changed over this period, the most likely explanation for this change was the increased use, and also the inappropriate use, of fluoridated toothpaste. "Inappropriate use" refers to swallowing toothpaste rather than spitting it out after brushing. On the recommendation of the forum on fluoridation, the Department of Health introduced two strategies to minimise fluorosis. The first of these was in relation to the appropriate use of fluoride toothpaste, and the second was to lower the level of fluoride in water, as I have mentioned.

The Deputy claims there are huge health questions surrounding fluoridation. A number of claims have been made in certain media concerning negative effects of fluoridation, alleging links to almost every conceivable illness. I am conscious that such claims, however erroneous, have potential to cause concern or even alarm. Consumers too, sometimes express concerns about potential negative effects on health of drinking fluoridated water or on the composition and source of fluoride or on the fact that other countries do not fluoridate their water supplies.

The National Cancer Registry has stated there is no good evidence to link fluoride levels in water, whether natural or added, to cancer risk. I welcome their reassurance in this regard.

It is important to continue to assess health statistics on a regular basis to address any concerns that general health may be affected by fluoridation. Accordingly, the effects of fluoride on health and related matters are kept under constant review, despite what has been alleged. This is required pursuant to sections 6 and 7 of the 1960 Act. As part of this ongoing work, an assessment of reviews on the effectiveness of fluoride and of general health databases is planned. Both reviews will be carried out systematically, with a particular focus on the Irish context. This work will be commencing shortly and will provide us with repeatable and rigorous search methods. The work on the general health databases will be supported by a general public health specialist. The chief dental officer, who was appointed earlier this year and with whom I work very closely in this area, will also have a key role in this regard.

Objective, independent reviews, conducted systematically, will serve a useful purpose in allaying any outstanding concerns of the public in this respect, particularly on general health issues. I am also committed to supporting ongoing original research to investigate and keep under review how fluoridation relates to oral and general health.

The Department of Health is collaborating in a research project, led by University College Cork, called Fluoride and Caring for Children's Teeth, which will specifically examine the oral health status of children and inform national policy. The study will consider the impact of changes on the oral health of children, following policy decisions relating to toothpaste use by infants and young children made in 2002 and the reduction in the level of fluoride in drinking water in 2007. It is focusing on five-year-old and 12-year-old children. The HSE has released dental staff and is providing funding to support the study.

Consideration is also being given to a study on general and oral health findings in adults linked to the duration of exposure to fluoridated water as part of The Irish Longitudinal Study on Ageing, TILDA.

Ireland is not alone in benefiting from water fluoridation. Many other countries have water fluoridation schemes too, including the United States, Canada, the United Kingdom, Spain, Australia and New Zealand. Data from 2012 for the United States shows over 185 million, 60% of the population, have fluoridated water. Over 80% of the Australian population, approximately 18 million, people have fluoridated water. Almost 5.8 million people in the UK have fluoride added to their water while another 330,000 have naturally fluoridated water.

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