Kathleen Lynch (Cork North Central, Labour) | Oireachtas source

I accept that.

The only known side effect of optimal water fluoridation is mild dental fluorosis, a condition known about since the 1930s. Dental fluorosis is a cosmetic or aesthetic condition which refers to the way teeth look. It is not considered to be an adverse health effect. At the levels of fluoride present in Ireland's water supplies, any occurrence of dental fluorosis is very mild or mild. In most cases, it is only detectable by a dentist as faint white flecks on the surface of the teeth.

Regularly conducted studies on dental health in Ireland, carried out when the upper limit for fluoridation was 1.0 part per million, confirm the low level of dental fluorosis. In the majority of cases, dental fluorosis generally does not require any treatment. The non-treatment of dental fluorosis has no health consequences.

The policy of fluoridation was the subject of a major review in 2000. A forum on fluoridation was established, comprising largely of persons with expert knowledge from the fields of public health, dental health, food safety, environmental protection, law and ethics, water quality and health promotion and a consumer representative. The main conclusion of the forum’s report, published in 2002, was that the fluoridation of public piped water supplies should continue as a public health measure. The forum also recommended that, given the increased access to fluoridated toothpaste and in light of the best available scientific evidence, the optimal level of fluoride in water should be redefined from the then level of 0.8 to 1.0 parts per million to between 0.6 and 0.8 parts per million with a target value of 0.7 parts per million. Parts per million is equivalent to milligrams per litre. This change was implemented by the Fluoridation of Water Supplies Regulations 2007.

Another important recommendation of the forum was that an expert body should be established to implement the recommendations of the forum, as well as advising the Minister and evaluating ongoing research on all aspects of fluoride. Accordingly, the expert body on fluorides and health was established in 2004. It continues to share its expertise and provide advice on fluoridation and related matters. It considers scientific evidence 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 the advice provided by the expert body is impartial and evidence-based. The expert body is satisfied, having studied current peer reviewed scientific evidence worldwide, that water fluoridation at the level permitted in Ireland does not cause any ill-effects and continues to be safe and effective in improving the oral health of all age groups. These views are supported by reputable international agencies and valid scientific articles and reviews.

It is worth noting 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 around half that permitted by EU legislation. Systematic and comprehensive reviews of fluoridation have been conducted in many other countries too including the United Kingdom, such as the York review in 2000 and the Medical Research Council in 2002, Australia in 2007, Canada in 2010, the European Union in 2011 and New Zealand in 2014. None of these reports established any basis for considering that artificially fluoridated water poses any systemic health risks.

Nevertheless, the Department of Health keeps the policy of water fluoridation under constant review. The work done by the expert body and what we learn from international studies have been invaluable. It is important the public is continually reassured about the use of fluoridated water. It is for this reason that we have asked the Health Research Board to undertake a review of evidence on the impact of water fluoridation at its current level on the health of the population and on the environment. This particular initiative will consolidate the research worldwide using a systematic approach. We expect to have a definitive report from the Health Research Board by the end of this year.

The Department is also collaborating in a University College Cork-led research project, Fluoride and Caring for Children's Teeth, FACCT. 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 fluoridation in drinking water in 2007. In addition, 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 aging, TILDA, has commenced.

I note the concerns expressed by Senators do not relate specifically to health but to an ethical argument, namely, freedom of choice. The suggestion is that it is the right of every citizen to choose whether their water is fluoridated. This is troublesome and, as far as I understand, not supported by the Supreme Court.

How would it operate in practice? Would there be two separate public water supplies, one that is fluoridated and one that is not? Clearly, such a system would be impractical and expensive beyond our current capacity. There are parallels with the ban on smoking in the workplace. Some people would like to have the freedom to choose whether to smoke in a workplace. However, the exercise of that choice can have a negative impact on the health of others. Therefore, we see the value in restricting an individual's freedom of choice when it impacts upon the health and well-being of others. Is it ethical to stop fluoridation if doing so leads to poor dental health? We have a duty to make that choice, informed by evidence and in the best interests of the public. Tooth decay has a significant impact on health and well-being and results in high costs to the individual and the State. It is largely preventable and, therefore, a high priority for oral health promotion.

The Oireachtas, in its wisdom, introduced fluoridation 50 years ago. The Department of Health continues to review this policy and sees no benefit in its cessation. The costs of cessation are likely to be considerable. Ceasing water fluoridation without putting in place an alternative programme would be very costly. Fluoridation is known to decrease dental decay substantially, for example, in the order of 40% in children, according to Irish health statistics. The lifetime cost per person is approximately €1 per annum. Ceasing water fluoridation would lead not only to the additional financial burden of treating tooth decay but also to social costs, as tooth decay can lead to pain, trauma, disfigurement, loss of teeth and function, problems with nutrition and growth, and work or school absenteeism.

In some European countries that do not fluoridate their water, fluoride varnishes are applied to children's teeth twice per year. In Ireland, screening is usually provided twice for children in primary schools, typically in second class and again in sixth class. The introduction of a similar programme in Ireland would mean that children would be seen 16 times in primary school. This would require a significant investment in personnel and resources. Water fluoridation is the most cost-effective method of preventing dental decay and overcoming the poor risk profile in Ireland.

The Nuffield Council on Bioethics in the UK published a landmark report on ethical issues in public health in 2007. It recognised the tensions between protecting personal autonomy and promoting the welfare of all. To quote from the report: "From an ethical and practical standpoint, an important dimension of public health policy is therefore to balance the liberal emphasis on choice and autonomy with the imperative to support those who do not have the opportunities to choose, because of, for instance, poverty or dependency." Given that fluoridated water does not smell or taste differently from non-fluoridated water, the freedom of choice argument is essentially a debate about whether individuals who have a personal preference not to drink water containing 0.6 to 0.8 parts per million of fluoride should be able to prevent the rest of society enjoying the considerable benefits afforded by fluoridation. It is the view of the Government that they should not.

I thank the Senator for introducing a topic that I have been examining for all of my life. The arguments on both sides will probably never be fully concluded.