Forum Minutes of Meetings - 10 May 2001

Minutes of meeting of the Forum on Fluoridation on 10 May 2001
Great Southern Hotel, Dublin Airport

Professor Pat Fottrell (Chairman)
Dr Wayne Anderson
Professor William Binchy
Professor John Clarkson
Dr Elizabeth Cullen
Dr Paddy Flanagan
Mr Oliver Fogarty
Ms Dorothy Gallagher
Dr Gerard Gavin
Dr Howard Johnson
Mr Kevin Moyles
Dr Joe Mullen
Professor Moira O'Brien
Dr Máire O'Connor
Professor Denis O'Mullane
Professor Miriam Wiley

Ms Nessa O'Doherty (Forum Secretariat)
Dr Miriam Owens (Rapporteur)

Dr Kevin Balanda
Professor Don Barry

Dr Dominique Crowley
Professor Cecily Kelleher
Dr Carmel Parnell
Dr Margaret Shannon (Forum Secretariat)


The Chairman welcomed all present including Professor Don Barry of the University of Limerick and Dr Kevin Balanda of the Institute of Public Health who have agreed to advise the Forum on bio-statistical issues.

Presentation by Professor Elizabeth Treasure of the University of Wales, Cardiff

Professor Treasure's presentation was based on her involvement in "A Systematic Review of Public Water Fluoridation" (otherwise known as the "York Review") which was carried out by University of York in conjunction with the University of Wales, Cardiff and the University of Leicester (September 2000).

A Q&A session followed the presentation. The following questions (Q) were asked by members of the Forum and/or the Bio-Statistical experts present and were answered (A) by Professor Treasure. (Comments are indicated by (C) - such comments were not necessarily contributed by the same member as had asked the initial/relevant question.)

Q. Was there any input from the public regarding their views in this Review?

A The public was not asked for their views on the issue of fluoridation itself but suggestions regarding papers for review were welcomed as were any comments/criticisms of the Review process itself.

Q. A recent BMJ article stated that in areas where water fluoridation was at 1ppm, the level of fluorosis was 12.5% - is this high?

A. It is necessary to decide what exactly is fluorosis - i.e. aesthetic or mild/mottling

Q. If water fluoridation is considered to be a mass medication, in addition to the studies looked at, is it not also necessary to have a randomised trial in order to show positive effects, if any, of fluoridation, in order to justify its continuation?

A. It has to be decided whether water fluoridation is mass medication or not - discussion required before this decision can be made; a randomised control trial of individuals is probably not possible without vast expense being incurred - however, a cohort study may be more practical. The "York Review" found no evidence for a need to cease water fluoridation but such a cessation would almost certainly lead to an increase in dental decay levels

Q. Who is looking for other/negative effects of water fluoridation?

A. There have been a lot of studies on alleged links between water fluoridation and cancer, bone fractures, etc., but no evidence has been found to substantiate such alleged links. While the "York Review" did not state (for example) that "water fluoridation does not cause Y", this is because it is not scientifically possible to state with certainty that "X definitely does NOT cause Y", but it is possible to state that "no evidence has been found that X causes Y" i.e. one can not prove a negative.

C. Dr Paul Connett criticised the "York Review" for not looking at animal studies

A. Where there is substantial human evidence there is no need for animal studies to be used.

Comment: it can be dangerous to over-rely on animal studies as results in humans can differ.

Q. Surprised at the inclusion of DDE index - can this be justified?

A. While Professor Treasure said she could not justify its inclusion scientifically, it is admitted that the Review may have over-estimated the level of fluorosis.

Comment from other member: the conclusions of the "York Review" were very similar to that of Dean's (in relation to fluorosis) which determined the Health (Fluoridation of Water Supplies) Act, 1960. The level of 12.5% probably matches what would be found in Ireland.

Q. If the Review were to be carried out again, would it be done in the same way?

A. The Review team had explicit terms of reference which constrained the study somewhat (i.e. cross-sectional data would have been useful instead of just longitudinal).

Q. The "York Review" uses terms used as low, moderate and high quality in terms of the studies reviewed - how were these terms defined? Is the term "high quality" not impossibly high to achieve?

A. The Review team expected to find (a) cohort studies which (b) involved fluoride; the quality measures used may have been vague and/or unnecessarily harsh; however, it is necessary to put this into context with other reviews regarding the standards which the studies were meant to achieve.

Q. Why did the Review use three (rather than the more usual figure of two) confounding variables in relation to the studies for inclusion?

A. The Review team decided that the three criteria used were necessary although, on reflection, it reduced fairly significantly the number of studies to be included in the Review.

Q. Why was there was a time requirement obligatory in a study in order for it to be included in the Review? i.e., studies had to start within one year of the commencement of fluoridation in that area

A. This was necessary so as to be able to attribute results to fluoride and not to any other factor.

Q. How many other studies could have been examined if the variables/criteria for inclusion had been relaxed somewhat?

A. Estimated that the number would have been quite high.

Q. Following the publication of the "York Review", a committee of Medical Research Council in the UK is considering the priority of research areas relevant to water fluoridation - what priorities have been identified so far?

A. This report has not been finalised as yet.

Comment: The Forum would be interested in hearing the Group's recommendations.

Q. Will the "York Review" have any impact on the legislative debate on whether authorities in the UK "may" or "shall" have water fluoridation?

A. This depends to a large degree on the legislative priorities of the next government.

Documentation forwarded by Dr Don MacAuley (copy of letter from Professor Trevor Sheldon in relation to the "York Review") was given to Professor Treasure prior to this meeting and she was asked for her comment on its contents. Professor Treasure explained that Professor Sheldon had been responding to certain press statements/coverage in relation to the "York Review" which may have been unwise in terms of how they stated the recommendations of the Review and he was, therefore, attempting to correct the balance. Professor Treasure reiterated that no evidence has been found linking water fluoridation to any harmful effects other than fluorosis but further research should continue.

A critique of the "York Review" submitted by Ms Catherine McNamara, Lecturer in Health Economics, was also forwarded to Professor Treasure prior to this meeting. When asked to comment on this, Professor Treasure said that Ms McNamara had taken issue with the "York Review" for its "lack of transparency" and a perceived "bias towards UK-based studies" (among other issues). In relation to the claim that the Review lacked transparency, Professor Treasure stated that the Review team's work was openly available to all interested parties during the Review itself on the web and comments/criticisms were welcomed at all stages - and all such comments/criticisms were examined and responded to. In relation to the second criticism (above), Professor Treasure explained that no attempt was made to bias towards UK-based studies as studies from many countries internationally were examined and it was also at the discretion of interested parties to suggest studies for inclusion; however, there was a limit to the number of studies that met with the variables for inclusion and the Review team's remit was to look at the situation for current-day UK. Professor Treasure stated that she is more than willing to engage in discussion with Ms McNamara on the Review. At the Chairman's request, Professor Treasure agreed to confirm the above in writing for the Forum.

The Chairman thanked Professor Treasure for her detailed presentation and for her flexibility in re-arranging her schedule following the cancellation* of the March 2001 meeting at which she was due to make a presentation.

(*March 2001 meeting cancelled due to Foot and Mouth Disease control measures).

Professor Treasure then left.

Professor Barry and Dr Balanda left after agreeing to advise the Forum on their conclusions on the statistical issues relevant to the "York Review".

Professor Binchy had to leave at this point due to prior engagement.

Presentation by Ms Margaret O'Neill, Community Nutritionist, South Western Area Health Board

Ms O'Neill gave a presentation on relevant nutritional issues related to dental health.

Dr Gavin and Ms Gallagher had to leave at this stage due to prior commitments.

A Q&A session followed Ms O'Neill's presentation. The following questions (Q) were asked by members and answered (A) by Ms O'Neill. Comments are indicated by (C).

Q. Is there a league table of countries regarding sugar consumption?

A. Ms O'Neill undertook to get one and to forward it to the Forum.

Comment: Ireland is near the top of any such league table.

Q. Are there any studies showing total daily intake of fluoride?

A. Ms O'Neill is not aware of any such study having been carried out so far but said that it should be possible to measure; Professor Mike Gibney of Trinity College, Dublin may be able to advise the Forum on this.

Comment: the Food Safety Authority of Ireland is examining the issue of fluoride intake in relation to infant formula at the moment and would welcome input from Ms O'Neill. University College (NUI), Cork also has a team looking at this issue.

Q. What is the dilution of infant formula?

A. One scoop of formula to one fluid ounce. The level of breastfeeding nationally is only at 30% but there is an on-going effort to increase this.

C. In relation to change of diet in order to decrease the level of dental caries, most studies carried out on sugar consumption show little effect in trying to get people to change their diet.

A. Agreed that it is very difficult to induce behavioural change; society needs to look at the way in which the health service (and other relevant sectors, including the various elements of the media) communicate with the public on general and dental health issues. It is important to enable people to change their diets - for example, it is recommended that one should eat several portions of fruit/vegetables each day - however, a parent who has no car may be unable to carry sufficient quantities for a family from a distant supermarket in order to stay in line with the recommendations. One positive example of inducing behavioural change is that of the school meals provided in socio-economic deprived areas - it has been shown that such meals have increased attendance quite significantly.

Comment: many people now need pre-prepared/fast food - it would be better to have more of this, of a higher quality, at a cheaper price. Maternity hospitals also need to try to divert more resources towards increasing the level of breastfeeding - this will require, among other factors, more nurses.

Q. Where were the statistics provided on infant formula from?

A. A study from the UK - will give more precise details if required.

Comment: studies show that where sugar is added to tea (high level of fluoride), the fluoride has no detrimental effect; although, admittedly, the tea used in China is green tea, there is a very low level of caries in that country.

Comment: Beijing is currently considering the introduction of water fluoridation.

Q. Are there any figures available on "sugar attacks" per day per social class?

A. Ms O'Neill said she was unaware of any studies on that particular question.

Professor O'Mullane said that a paper was presented recently in Belfast (by a UCC student) concerning the fluoride content and pH levels of various drinks - he will provide the figures contained therein to the Forum if this is helpful.

Q. Ms O'Neill had stated during her presentation that she is the only Community Nutritionist dealing with an area of 500,000 people (but not all health boards are similar in this respect); how would this compare to the UK?

A. Ireland is far behind the UK in terms of staff resources in the health promotion area but some health boards here are better than others. Ms O'Neill agreed to supply some international comparisons on this.

Q. Are claims made in relation to certain drinks, which are currently being advertised, as kind to teeth justified?

A. This is a controversial area. Labels can be confusing and/or misleading.

Comment: while it is important that labelling be more specific, accurate and clear to the public there is no legislation currently underway to bring this about. On this topic, Dr O'Connor said that she was involved in a study of school children's eating habits - it was discovered that parents can honestly feel they are feeding their children healthy food but may be misled by packaging. Media and marketing coverage can sometimes increase confusion. It was also seen in the study in which Dr O'Connor was involved that the majority of mothers have decided whether or not to breastfeed before they give birth - so if a change is to be brought about in the level of breastfeeding mothers resources need to be applied at any earlier stage during pregnancy.

Dr Johnson explained to Ms O'Neill that he is currently working on the Health Information Strategy and would welcome her views.

The Forum may need further advice on nutritional aspects - Ms O'Neill said she was willing to advise the Forum as required and that members of the Forum may contact her at any stage for information.

The Chairman thanked Ms O'Neill for her interesting presentation. Ms O'Neill then left.

Professor O'Brien had to leave at this stage; the Chairman mentioned to her that a response to Dr Paul Connett's e-mail regarding the minutes of the Forum's meeting in November 2000 is required - Professor O'Brien agreed to write to him.

Presentation by Professor Denis O'Mullane

Professor O'Mullane made a presentation regarding the research contract awarded to the Oral Health Services Research Centre by the Department of Health and Children regarding fluoridation.

Dr Johnson had to leave at this point due to prior commitment.

A Q&A session followed the presentation. The following questions (Q) were asked by members and answered (A) by Professor O'Mullane. Comments are indicated by (C).

Q. How does one measure the level of toothpaste ingested by young children?

A. It is very difficult to do but it is monitored carefully and standardised.

Q. How much is a pea-sized quantity of toothpaste meant to be?

A. 0.3g.

Q. Does the research take into account (a) the person's diet and (b) other health factors, when measuring the amount of fluoride excreted?

A. It is not possible to control for every possibility but it can be measured effectively in terms of what is ingested and what is excreted and then compared to non-fluoridated areas.

Q. Data on the fluoride levels of beverages measured would be very useful; had research team noted the country of origin of all of the beverages studied?

A. This information can be provided if required.

Comment: some foods advertise the fact that they are low in sugar but often such foods have a high acidic make-up - and if food is high in either sugar or acid it may damage teeth. Since the 1980's (approximately) people have been concerned about food additives - yet it is still difficult to get convenience food without them. A lot of food on the market (including sauces, toppings, dressings) are very acidic due to the amount of preservative contained therein.

Question asked of Dr Anderson:

Q. Is it possible to neutralise such acid in food?

A. It is possible (by adding cream or milk, in some instances) but certain socio-economic groups would not have the resources (financial/time) available to them to do so.

The Chairman thanked Professor O'Mullane for his detailed presentation.

Minutes of meeting of 5 April 2001

The minutes of the meeting of Thursday 5 April 2001 were agreed.

Matters arising

(a) Ms Dora Hennessy has been re-assigned within the Department of Health and Children and has, therefore, resigned from the Forum. The Forum agreed that while the decision whether to replace Ms Hennessy is at the Minister's discretion, it was felt that it would not be appropriate to introduce a new member at this stage due to the amount of work already carried out. The Chairman asked the Secretariat to prepare a letter thanking Ms Hennessy for her contribution to the work of the Forum.

(b) As mentioned above, Professor O'Brien will respond to Dr Connett's e-mail regarding the minutes of the Forum's meeting of November 2000. A copy of correspondence in this regard will be given to the sub-group dealing with Dr Connett's "50 Reasons".

(c) The Forum's radio advertisements thanking respondents to the request for submissions ran during the week commencing 30 April 2001. The newspaper advertisements ran on 4, 6 and 13 May 2001.

(d) The British Fluoridation Society wrote to the Forum seeking information on/text of several documents forwarded to the Forum (i.e., presentations, submissions) for their use. It was agreed that the Secretariat would contact each of the relevant individuals to seek their views on this matter.

(e) Future guest speakers/presenters:

June 2001
Professor Binchy (regarding paper circulated today)
Ms Doreen Wilson, Chief Dental Officer, Northern Ireland
Dr Patrick O'Sullivan, IDEA
Dr Andrew Rynne

July 2001
Ms Darina Allen
Dr Caswell Evans**
Dr Jacinta McLoughlin

** Professor Clarkson, Dr Mullen and Professor O'Mullane agreed to consider areas that need to be addressed during the presentation of Dr Evans.

(f) Ms Claire Chambers of the Irish Society of Toxicology will be contacted shortly by the Secretariat in order to discuss that Society's presentation and advisory role.

(g) Full-day meeting in July 2001. No meeting in August 2001 because several members will be on holiday.

(h) Professor Clarkson agreed to write to the Centre for Disease Control in the US regarding engineering aspects of fluoridation. Mr Moyles agreed to liaise with him regarding information required on the acid.

(i) A reply is required for Dr Don MacAuley's correspondence - Dr Flanagan's sub-group will draft the response.

(j) Sub-group on Public Consultation

This group has met to examine the submissions received. Approximately 1,000 submissions have been received to date of which 15 are from professional/technical groups and associations. The sub-group will prepare a report on the views contained in the submissions and the concerns raised therein. The two most frequently expressed concerns are (i) lack of choice and (ii) fears of alleged health effects.

(k) The sub-group drafting responses to Dr Connett's "50 Reasons" will meet shortly; while the group is making progress a significant amount of work is still required in order to address all of the Reasons comprehensively.

(l) The sub-group dealing with the concerns raised by County Councils agreed to draft a letter to explain the Forum's progress to date.

(m) Dr Owens went to visit the Albatross plant recently. Albatross agreed to submit a summary of the process involved in preparing in the hydrofluosilicic acid. Information regarding the purity of the acid used will be drafted in response to (k) above.

(n) The date for presentation of the Forum's recommendations has been extended by one month (to the end of October 2001) due to the cancellation of the March 2001 meeting.

(o) Several Freedom of Information requests have recently been received in relation to the Forum - while the Forum agreed unanimously that these should be complied with fully and openly, concerns were raised that the large time commitment and workload involved in preparing such responses would hinder the day-to-day work of the Secretariat. The Freedom of Information Officer from the Department of Health and Children and an independent expert will be consulted to clarify matters regarding such time-consuming requests.

Each member present was given several minutes in which to articulate their views on the work of the Forum to date, any concerns they may have and any other issues that they feel relevant. It was made clear by all members that they are examining the issue of water fluoridation with an open-mind; no decision will be made by any member regarding the cessation or continuation of fluoridation until all areas of concern have been addressed comprehensively.

Dr O'Connor

- discussions to date have been wide-ranging and thought-provoking but it is important to bear in mind the Forum's terms of reference i.e. public piped water supplies in Ireland
- very concerned that several groups/individuals invited as members/guest speakers (notably those who hold anti-fluoridation views) have declined invitations - it is important that all views be ascertained; it should be clarified in the Forum's report as to which groups declined to participate
- regrets missing the presentations given by Dr Connett and Professor Limeback (due to prior commitment)
- the presentations made by Drury Research/Dental Health Foundation and Dr Beirne were useful in ascertaining the public perception of the issue
- the presentation made by Ms O'Neill was very interesting and helped to put factors such as attempting to induce behavioural change via health promotion in context
- if, following comprehensive consideration of all relevant factors the Forum decides to recommend that water fluoridation continue, it needs to identify prioritised areas for health boards and local authorities in implementing the process eg planning
- research needs may differ between, and even within, health boards.

Professor Clarkson

- the Forum's work is progressing well
- work of the sub-groups has been useful in addressing key issues
- how far does the remit of the Forum extend?
- whether the Forum recommends that fluoridation should cease or not, it is essential that the Forum finds solutions for the Irish context
- while the Forum's schedule has been extended by one month there is still a considerable amount of work to be done
- it is very unfortunate that several groups/individuals declined invitations to participate in and/or speak to the Forum - this point should be highlighted in the Final Report; in this respect Dr Connett and Professor Limeback who are opposed to water fluoridation are to be commended for coming
- the issue of total fluoride exposure needs to be addressed and monitored
- it is regrettable that Professor Whitford has had to decline an invitation to speak to the Forum due a heavy schedule of prior commitments as his insights would have been useful
- more information is required on the effectiveness, or otherwise, of fluoridation in Ireland
- the issue of alleged contaminants in the acid needs to be addressed thoroughly
- if the Forum recommends that water fluoridation be reduced/removed, it is necessary to look at what possible knock-on effects this would have and what alternatives are acceptable and effective
- while the issue of safety in relation to the public's health is essential, the only negative effect of fluoridation agreed on unanimously to date is that of dental fluorosis
- the ethical aspects relating to water fluoridation are very important - Professor Binchy's paper on this will be vital
- if the Forum recommends that water fluoridation should continue, it is essential that research be on-going.

Professor Wiley

- the variety of issues covered by the Forum is very useful, particularly to a non-scientific member such as herself
- the Forum will be providing a substantial amount of information on its work/findings and this is a positive step
- two important issues are (a) safety and (b) freedom of choice - it is necessary to address both - clarity will help to allay fears
- it is important that any information presented by the Forum be in a reader-friendly style so as to be accessible by as wide an audience as possible
- it is important not to under-estimate the strength of anti-fluoridation opinion
- the overall policy decision on this issue is up the Minister.

Dr Anderson

- the Forum needs to address different perceptions i.e. what level of caries is acceptable? This level may differ from a member of the public to a dentist. The presentations to date have not addressed this question.
- if the Forum recommends the cessation of water fluoridation, will the level of dental health/ dental decay in Ireland revert to that of the 1960's? (ie prior to commencement of fluoridation) - this may be unlikely due to vast changes in society etc
- addressing Dr Connett's "50 Reasons" is fundamentally important
- how can the Forum address misconceptions of the public?
- concerns expressed in submissions received need to be fully addressed
- the Forum has not yet addressed toxicological issues but it is important that this be done
- what is a safe level of fluoride?
- if the Forum recommends that fluoridation should continue, does the Forum need to draw up a code of practice?
- does the Forum need to take account of background levels of fluoride in ground water or is this outside its remit?

Mr Moyles

- water fluoridation may have been necessary in 1960's but big improvements in dental hygiene since then may have removed the need for it; however, water fluoridation still appears to be the best option for poorer people in society
- if fluoridation is found to be safe and beneficial then the Forum needs to decide how it should be administered
- if doubts regarding alleged harm are to be adequately addressed more research may be necessary
- a lot of the submissions received raised the issue of purity of acid used - the EU is about to issue draft standard for this product; perhaps representative of Centre for Disease Control could advise the Forum on the issue of purity and related issues
- it is important that Dr Connett's "50 Reasons" be answered comprehensively
- the Health (Fluoridation of Water Supplies) Act, 1960 requires surveys to be done - this needs to be looked at
- the Act also states that the water needs to be analysed regularly - if the Forum recommends the continuation of water fluoridation, the method stated for such analysis needs to be amended to take account of current scientific practice and future developments - is willing to provide Forum with draft wording in this regard if required
- the issue of the level of fluoride in infant formula needs to be examined.

Dr Flanagan

- while discussions so far have been good, it is disappointing that several groups/individuals declined invitations to participate - this should be highlighted in the Forum's report
- ethical aspects are crucial, particularly in view of the concerns expressed in this respect in the submissions received
- misconceptions of the public need to be addressed as do all concerns voiced in the submissions
- health surveys are necessary
- the Forum's report should open with the views of the public - criticism should be acknowledged and welcomed
- the Sub-Group on public consultation will present its report to the Forum at July 2001 meeting.

Mr Fogarty

- pointed out that he is making observations as a non-medical member of the Forum
- most issues have been addressed adequately
- the case made against fluoridation has thus far not been very strong but he remains open-minded on the issue
- very disappointed that VOICE, Dr MacAuley and others declined invitations to participate as anti-fluoridation views from an Irish context are important for a balanced examination of the issue; however, it was very worthwhile to hear the presentations made by Dr Connett and Professor Limeback, both of whom are opposed to water fluoridation
- infant formula is a key issue
- the paper presented by Mr Parle (Principal Environmental Health Officer) was important and follow-up on the issues raised by him is crucial
- if the Forum recommends the continuation of water fluoridation, then it is crucial that a target date be set for improvements in implementation
- consistency and engagement of all stakeholders are necessary
- if fluoridation is to continue, then the work of the Forum is only a starting-point - another system/body to review the system regularly is essential until such time as fluoridation is deemed to be no longer needed
- alternative dental products - there is a high level of public misunderstanding which needs to be clarified
- local authorities are very isolated in the fluoridation process - more communication is needed between all relevant bodies.

Dr Mullen

- if the Forum recommends the cessation of water fluoridation it would not mean a return to pre-1960's level of dental caries but there would be some regression; the number of general anaesthetics used during certain dental treatments would also increase
- spent a week at the Evidence Based Dentistry Centre in Oxford - as part of this the "York Review" was discussed and it was concluded that while the studies used were not of the highest quality it was still reasonable to draw conclusions from them
- the Forum has covered dental and medical aspects well but has not covered environmental issues in sufficient depth - this had been why Dr Connett was initially suggested for a presentation; perhaps another environmental expert from the anti-fluoridation perspective could be considered/invited?
- interface between health boards and local authorities needs to be improved.

Brief discussion followed concerning environmental issues; while this issue may be outside the remit of the Forum it was agreed to discuss the need for a further speaker at the meeting in June 2001. It was also agreed that Professor Paul Dowding in TCD be invited by the Secretariat to make a written submission on the impact of fluoride on the general environment.

Professor O'Mullane

- agrees with many of the points already raised
- very disappointed that several Irish groups/individuals who are opposed to water fluoridation declined to engage in the process
- how should the Forum deal with conspiracy notion? As discussed earlier during this meeting, it is not possible to say with scientific certainty that "X does not cause Y" - but in the case of fluoridation it may be difficult for members of the public to make this distinction
- a lot of studies have been carried out under the Health (Fluoridation of Water Supplies) Act, 1960 - offered to make a list of these studies available to the Forum
- agreed with Dr Anderson that it is important to agree a level of dental caries which is acceptable ie what is the specific objective of fluoridation?
- the issue of fluorosis is the one negative effect of fluoridation which has been proven but this was known prior to the introduction of the 1960 Act
- there is a need to concentrate on Irish studies
- the Forum's Final Report will be very important.

Dr Cullen

- happy to be a member of the Forum
- two concerns ie (a) absence of representative from anti-fluoridation perspective on the Forum - while the IDEA is not in favour of fluoridation, it is not representing the anti-fluoridation perspective, (b) the expertise required in relation to renal, paediatric and toxicological issues has not yet been tapped
- a speaker such as Professor Paul Dowding would be important
- could the Forum meet in Wexford and visit the Albatross plant?
- would like to know what weight the submissions will have in the overall recommendations/report.

Dr Owens

- two paediatricians have been written to and asked to advise the Forum - no reply as yet
- spoke to Dr Joe Treacy of the Toxicology Unit in Beaumont - he is happy to advise the Forum but requires further details on which area(s) to focus
- some of the presentations may not have been totally relevant to the subject of fluoride but have a bearing on the overall discussions/considerations.

Following a request from Dr Cullen it was agreed that Dr Treacy would be asked to meet Dr Gavin, Dr Owens and Dr Cullen to discuss issues of concern in relation to toxicological issues - this will be arranged by Dr Owens.

NB Any member who was not able to participate at this meeting due to prior/conflicting engagement is asked to give their views at the meeting in June 2001.

Professor Fottrell thanked everyone for their excellent contribution to the work so far and asked them to continue to do so as there is much work ahead.

Meeting concluded.

Next meeting on 14 June 2001.

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