Forum Minutes of Meetings - 14 June 2001

Minutes of meeting of the Forum on Fluoridation on 14 June 2001
The Boardroom, Dublin Dental Hospital

Present

Professor Pat Fottrell (Chairman)
Professor William Binchy
Professor John Clarkson
Dr Elizabeth Cullen
Dr Paddy Flanagan
Mr Oliver Fogarty
Dr Gerard Gavin
Dr Howard Johnson
Professor Cecily Kelleher
Mr Kevin Moyles
Dr Joe Mullen
Professor Moira O’Brien
Dr Máire O’Connor
Professor Denis O’Mullane
Dr Carmel Parnell
Ms Nessa O’Doherty (Forum Secretariat)
Dr Miriam Owens (Rapporteur)

Apologies

Dr Wayne Anderson
Dr Dominique Crowley
Ms Dorothy Gallagher
Professor Miriam Wiley
Dr Margaret Shannon (Forum Secretariat)

Meeting

Apologies were given for the members who could not attend this meeting.

Minutes of Meeting of 10 May 2001

The minutes of the meeting of Thursday 10 May 2001 were agreed.

Matters arising

Dr Crowley is resigning from the Forum after this meeting for personal reasons. The other members of the Forum asked for it to be put on record that Dr Crowley’s in-put into the Forum had been valuable and much appreciated.
The Secretariat contacted Ms Darina Allen to re-confirm the details for her presentation which was scheduled for the Forum’s meeting in July 2001; Ms Allen has decided not to proceed with her presentation and will write to the Secretariat shortly outlining her reasons for this decision.
The Forum noted that Fluoride Free Water is marching to the Department of Health and Children today.
Ms Claire Chambers of The Society of Toxicology had requested some details (eg levels of fluorosis, level of naturally occurring fluoride in ground water, level of fluoride in mouthwashes, toothpastes, etc) in order to assist the Society to prepare their submission to the Forum. At the invitation of the Secretariat, Professor Clarkson spoke to Ms Chambers on these matters. The Society will now proceed to prepare a submission.
Professor Clarkson has been in contact with Mr Tom Reeves of the Centre for Disease Control in the USA, an internationally recognised expert on hydrofluosilicic acid – the latter has forwarded some information in relation to the acid and has also offered to speak to the Forum if required. It was agreed that it is important to have an expert on this area to speak to the Forum and the Secretariat will proceed to invite Mr Reeves to the meeting in July 2001.
Approximately fifteen submissions were received by the Forum from expert/professional bodies – these will need to be examined by members of the Forum with the relevant expertise. A list will be circulated to the members of the Forum. Dr Flanagan will draft a summary of the findings of the Sub-Group on Public Consultation which he will circulate to the members of that Sub-Group shortly – this summary will highlight the list of concerns most frequently raised by respondents. Ms Gallagher and Dr Cullen are taking a detailed look at the submissions to check the accuracy of the summary.
The Chairman asked that all sub-groups try to finalise their work before the end of June in order that their findings/results can be presented the meeting in July 2001.
A journalist from the Irish Times has asked to look at the submissions received – it was agreed that the Forum has no objection to this in principle; however, respondents may have forwarded their views on the understanding that such submissions were private and would not be viewed by any third party. It was agreed that the submissions should not be released until after the Sub-Group on Public Consultation has completed its examination. It was noted by members that it is not possible to contact each respondent due to the fact that full addresses were not necessary/provided. It is important, however, that the Forum be as open as possible.
Some newspapers articles (circulated to the members before this meeting) mentioned that a specific journalist had not been successful in his attempts to contact members of the Forum. Three members of the Forum stated that they had taken calls from the relevant journalist and had explained that the Chairman had requested that, in the best interests of the work of the Forum, members should refrain from making public pronouncements on the subject of fluoridation until after the Forum’s recommendations are presented to the Minister. The Chairman had pointed out that any individual comments could compromise the work of the Forum by appearing to pre-judge the Forum’s conclusions. The members of the Forum are open-minded on the subject being examined and all conclusions of the Forum will be reached following full and balanced consideration. While the tone of some articles has been negative, it is more important for the Forum to continue its work than to respond to individual articles.
The members were advised that the Department’s Freedom of Information Officer has written to Dr Don MacAuley regarding his requests and, in view of the large time commitment which would be involved in collating the material for response, asked for a deposit to be paid. A response is awaited from Dr MacAuley.
Professor O’Mullane, as Chairman of the Sub-Group working on responding to Dr Connett’s "50 Reasons", explained that this is an enormous and very detailed task and is taking a lot of time to compile; it is hoped that the response will be completed by the end of July 2001.
In relation to the Sub-Group on Alternatives, Professor Clarkson explained that he and Professor O’Mullane are working on a paper which their sub-group will discuss.
The Sub-Group on Ethics met in Cork on 12 June 2001 – Professor O’Mullane said that the meeting was useful but a lot of work is still required. It was agreed that further expertise was required in order to advise this Sub-Group – the Secretariat will liaise with Professor O’Mullane with a view to contacting a specialist in that field.
Dr Cullen is extremely concerned that the issues raised by the IDEA in relation to nephrology and toxicology have not yet been adequately addressed. Dr Owens explained that attempts have been made to elicit advice from two paediatric/nephrology specialists and a toxicologist; the latter is unable to meet the Forum due to a heavy workload but is very willing to advise the Forum on relevant issues. The Secretariat mentioned that the Society of Toxicology is willing to meet the Forum but this may not be possible in time for the meeting in July 2001 due to prior commitments; however, the Society is currently working on its submission to the Forum. A commitment was given to Dr Cullen to follow up on the need for advice on the issues raised by the IDEA. Suggestions regarding the names of other experts in the field of nephrology were requested from the members of the Forum.
Dr Owens stated that the progress report is almost finished and will be on the Forum’s web site shortly.
A response has recently been received from VOICE following the Chairman’s letter to the organisation.
The meeting on 12 July 2001 will be lengthy as there will be several presentations and the Forum has a lot to discuss on that date.
The two Bio-Statisticians (Professor Don Barry and Dr Kevin Balanda) have been in contact with each other following the presentation by Professor Elizabeth Treasure on the "York Review" – the Secretariat expects a written report on their conclusions shortly.
Dr Mullen, on behalf of the Sub-Group to meet the County Councils, has drafted a letter to be issued to the Councils.
Professor Kelleher stated that her staff would be more than willing to provide any additional information/data required on nutritional aspects, particularly in relation to any questions raised following the presentation by Ms Margaret O’Neill, Community Nutritionist. The Chairman requested, in particular, an international league table of sugar consumption.
The guest presenters at the next meeting will include Dr Caswell Evans (USA) and Dr Jacinta McLoughlin (DDH). The Secretariat will also try to have a toxicologist present – any member with concerns regarding toxicological issues should forward these in writing to the Secretariat in advance.
Professor Paul Dowding will be asked by Dr Cullen, on behalf of the Forum, to submit his views from an environmental perspective.
Dr Owens, Rapporteur, is to prepare the outlineof the first draft of the Forum’s report and circulate it to the members of the Forum before the meeting in July 2001 – the second draft will be done in August 2001 and the third in September 2001. NB No recommendations will be made or included in the draft until after the Forum has fully completed its examination and discussion process. The deadline for presentation of the report is now close and it is important that the Forum make significant progress on the report over the summer period.
Reference was made to the fact that Japan is considering introducing water fluoridation.
It was noted in relation to hydrofluosilicic acid that the levels shown in the documentation from Dr Cullen (which was circulated to the Forum) would indicate a very pure quality of acid used for fluoridation. It is important to remember that although minerals such as arsenic or chromium are present in very small quantities in the original acid there is a very high dilution factor after addition to water which results in extremely low final levels which are in no way harmful.
The term "waste product" which is often used in the media in relation to hydrofluosilicic acid is incorrect and will be explained in detail in the final report of the Forum and by Mr Tom Reeves of the Centre for Disease Control.

Presentation by Professor William Binchy – "Fluoridation – The Legal Dimension"

The presentation was followed by a brief Q&A session.

How would the European Court decide on the issue of water fluoridation?

Extrapolating from relevant decisions made by the European Court so far would appear to indicate that it would not be struck down.

The Chairman thanked Professor Binchy for his well-researched and informative presentation.

Professor Binchy left at this stage due to a prior engagement as did Dr O’Connor.

Presentation by Ms Doreen Wilson, Chief Dental Officer, Northern Ireland – "Mid Term Evaluation of the 1995 Oral Health Strategy"

The presentation was followed by a Q&A session.

Dr Mullen commented that he is involved in cross-border work; the North Western Health Board often have dentists from Northern Ireland who express surprise at the difference in the level of dental caries between the two areas – and if one looks at the fluoridated areas of the Republic of Ireland v non-fluoridated Northern Ireland the difference is even more marked. Northern Ireland is considerably ahead of the Republic of Ireland in terms of oral health promotion strategies but, nevertheless, the Republic of Ireland has significantly fewer dental cavities. Ms Wilson stated that huge resources have been put into oral health promotion in Northern Ireland in the past five years but there has been very little impact as a result, which is disheartening. In her experience as Chief Dental Officer Ms Wilson said that if there is no water fluoridation then massive resources are required for alternative strategies which have had limited success. However, such a decision would necessitate discussion on where resources are best targeted in the health sector where there are so many competing demands.

Secretariat is to get a copy of the Oral Health Strategy from Northern Ireland.

What are the party political views on water fluoridation in Northern Ireland?

None given so far but Minister de Brún is very anxious to reduce social inequalities. Any decision regarding the introduction of water fluoridation in Northern Ireland would require in-depth consultation.

In 1997 the relevant Minister decided not to have water fluoridation in Northern Ireland – why?

It was anticipated that there would be a lot of opposition at County Council level. However, debate now could be very valuable as the decision would be made locally (ie in the Assembly) rather than in London.

How is the British situation so close to Ireland’s when they only have a small amount of water fluoridation? Is diet a more important factor than had been realised?

Social deprivation is an important factor, most particularly in Northern Ireland.

In the absence of water fluoridation, what other strategies could be considered?

An intense programme including fluoride mouthwashes/rinses, oral health promotion, healthy eating projects, free toothbrushes, etc. Society needs to change its eating habits – however, inducing this change is very resource-intensive and has had limited success.

Has either fluoridated salt or milk been considered?

Both will be looked at in Northern Ireland, as will fluoridated toothpastes and fluoridated water.

Comment: Evidence from pre-1960 period indicated a very similar dental health situation in Northern Ireland to that of the Republic of Ireland – ie starting from the same point – but there is a large difference in dental cary levels now in spite of enormous efforts made in Northern Ireland on alternatives to water fluoridation.

Comment: There is an important opportunity cost to be considered here ie spending money on fluoridation or alternative methods of oral health promotion – could that have a cost elsewhere in the health sector?

Ms Wilson stated that a large amount of money has been invested in oral health services in Northern Ireland (UK£66m for one million population approximately) but matters have basically stood still. The projected revenue cost of fluoridating Northern Ireland’s water supplies (UK£2m) would be a very small fraction of this cost.

Members were reminded that a paper by Mr Tim Holland of UCC in relation to the cost-effectiveness of different methods of fluoride delivery has recently been circulated by the Secretariat – this may be of interest in relation to this discussion.

Is Northern Ireland evaluating dental health promotion strategies to see what is or is not working effectively?

Not as such – but different strategies can reach different parts of society. There is a need to place responsibility on the individual for their own dental health.

Does health promotion work?

It is a matter of scale and how much is invested – it also depends on the margin of gain desired.

Comment: If you persist at health promotion, it will work eventually.

Comment: Yes, but the issue of equity is at play.

To what extent has paediatric toothpaste usage been effective?

This is very difficult to get information on but work on this area will continue.

Ms Wilson, as Chief Dental Officer, said she would like to raise the profile of dentistry in society in Northern Ireland.

The Chairman thanked Ms Wilson for her interesting and well-prepared presentation. Ms Wilson then left.

Presentation by Dr Patrick O’Sullivan, Irish Doctors’ Environmental Association (IDEA) – "Position Paper on Fluoridation"

Dr O’Sullivan said he was grateful for the opportunity to participate in this debate. The IDEA welcomes the Forum and its work.

A Q&A session followed the presentation.

Q. If the questions raised by the IDEA were dealt with satisfactorily by the Forum, would the IDEA still have a fundamental problem in principle with water fluoridation?
A. The IDEA members on the whole dislike the addition of unnecessary chemicals to anything - in the scenario detailed in the Question above, Dr O’Sullivan would not personally have a problem with fluoridation but other members of the IDEA might.

Comment: Very strongly concerned with the need to address socio-economic differences – but examination of this issue leads to examination of different aspects of risk eg relative, absolute or attributable risk. It is crucial to examine alternatives and to bear opportunity cost of any decision made in mind.

Dr O’Sullivan agreed that it is necessary to look at the size of gain versus the potential for harm.

Comment: Dr O’Sullivan’s assertion that some reports link fluoridation to increases in cancer is incorrect – one needs to be very careful when quoting studies. However, in Dr O’Sullivan’s defence, it is extremely difficult to know which studies one can rely on – often they have to be examined in conjunction with other studies. The Chairman invited the IDEA to submit papers/references in support of their arguments and the Forum will examine them thoroughly. It was stressed that such references should be from peer-reviewed internationally recognised journals etc.

Comment: Agreement with Dr O’Sullivan that the issue of fluoridation and premature babies needs to be examined.

Comment: In relation to the "York Review", one of the difficulties in this regard is that no epidemiologist can prove something is safe – but one can say (as the "York Review" team did) that there is no evidence to prove it is not safe.

Dr O’Sullivan is very concerned regarding contaminants in hydrofluosilicic acid.

Comment: The principle "First Do No Harm" must always be borne in mind. In addition, there are issues of omission as distinct from commission to consider – eg to remove something which is of benefit to many may also be wrong.

Secretariat to get copy of the Combat Poverty Strategy Report from Professor Kelleher.

The Chairman, on behalf of the Forum, expressed his admiration for Dr O’Sullivan for his willingness to express his views to the Forum and reiterated that the Forum regrets deeply the fact that several individuals/bodies with anti-fluoridation views have declined invitations to meet the Forum to convey their views. Dr O’Sullivan (on behalf of the IDEA) was thanked sincerely for his contribution to this important participative process.

Presentation by Dr Andrew Rynne on his concerns regarding fluoridation and the Forum on Fluoridation

A Q&A session followed this presentation.

The Chairman, on behalf of the Forum, thanked Dr Rynne sincerely for meeting the Forum and for conveying his views. It is essential that views from all perspectives be heard by the Forum in order for the debate to be fully rounded; the Forum has expressed, on several occasions, its disappointment and regret that several individuals and groups with anti-fluoridation views have declined invitations to meet the Forum. It is particularly laudable in this case that Dr Rynne had the courage of his convictions in putting his views across. However, both the Chairman and members of the Forum were anxious to point out that, despite Dr Rynne’s assertion to the contrary, each member of the Forum is looking at the issue of fluoridation in an open-minded manner. Dr Rynne pointed out that, in his opinion, it would be very difficult for a member of the Forum who may have previously supported water fluoridation to express any anxiety in this regard now as this may have an impact on his/her professional reputation; again, the members pointed out that if new scientific evidence were found by the Forum pointing to any harmful effects they would have no problem in expressing this – it would not be an admission of error but an acceptance of new evidence and learning. As one member pointed out, the health and safety of his family and friends are of more importance to him than his professional reputation – no member of the Forum would seek to advance dental health at the expense of general health if evidence of alleged harmful health effects were found.

The Chairman stated that the Forum would welcome any peer-reviewed evidence which Dr Rynne would like to submit in support of his arguments.

It was mentioned to Dr Rynne that over 1,000 submissions from the public and interested bodies have been received by the Forum – the views contained therein are being examined and will be treated fairly.

The Chairman reiterated that the Forum has not yet decided what recommendation(s) it will make – examination of the issue is not yet complete; it is important to look at all of the concerns raised.

It was mentioned to Dr Rynne that most of the points raised by him have already been raised by other speakers/submissions and the Forum will be addressing all of them. The members of the Forum come from varied professional backgrounds – this multiplicity of expertise will be of great benefit to the Forum in examining the different concerns.

There is need for more scientific research in this area.

The issue of freedom of choice is an important one for consideration and discussion.

Dr Rynne said that the Forum would not be providing any new studies or come up with any new information – he would like to see funding for new studies being provided and fluoridation to cease. The Forum agreed that, regardless of what other recommendation(s) it may make, it will definitely recommend that further research be carried out.

Dr Rynne said that fluoridation may have had dental benefit in the past but is not sure that this benefit continues now. Reference was made by a member of the Forum to a new study of adult dental health which will help to evaluate fluoridation – Dr Rynne is welcome to look at this study and to comment on it.

The Chairman thanked Dr Rynne for his clear and concise presentation. Dr Rynne then left.

Informal presentation by members of the Forum*

(*Most members had been given the opportunity to give their informal presentation at the meeting in May 2001; those who were unable to do so due to a prior/conflicting engagement were invited to do so at the June 2001 meeting)

Professor O’Brien

is looking at this issue in a totally open-minded manner
has learnt a lot from this process
the issue of premature babies should be examined thoroughly
the issue of dialysis patients should also be looked at but is not aware that tap water is used during this process
the Forum is an excellent opportunity to explore the issue of fluoridation openly, accurately and scientifically.

Professor Kelleher

this debate has opened up fascinating avenues of thought
the advantage of interdisciplinary exchange between Forum members is great
the Forum needs to decide on a level of benefit which is sought and weigh that against other arguments
the issue of errors of omission versus commission is fundamental to this whole discussion
while it is far too early to know if the Forum will recommend the continuation or cessation of water fluoridation, in the event that it continues a cohort surveillance system needs to be carried out rather than sectional surveillance.

Professor Kelleher mentioned that she is going on sabbatical for six months and will be, therefore, unable to attend any further meetings – however, she is anxious to continue her participation in the work of the Forum and will provide any advice and/or support required.

Dr Parnell

came to the Forum with a neutral attitude
the weight of evidence shown so far to the Forum would appear to sway in terms of the benefits of fluoridation – however, much research needs to be done
has been concerned all along regarding the philosophical/ethical view eg including the issue of breach of bodily integrity, but Professor Binchy’s presentation has allayed some of her concerns in this regard
societal values change constantly – not sure how the Forum will address this, but it is important that the views of the public be taken into consideration.

Dr Gavin

will provide his views in written form.

Dr Johnson

has no agenda on this issue and is proceeding on an open-minded basis
while scientific data is very important, the philosophical debate is very challenging and important
the very best scientific evidence available needs to be used in this process.

Next meeting on 12 July 2001.

NB Amendments to minutes above

At the Forum’s meeting of 12 July 2001, Dr Cullen asked that it be noted in relation to paragraph 14 above that in addition to the issues of toxicology and nephrology, she also expressed concern that the ethical issues in relation to fluoridation have not yet been addressed thoroughly

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