Concentration of fluoride added to drinking water in fluoridated areas of England

Gwrthodwyd y cais gan Public Health England.

Dear Public Health England,

When water fluoridation was first proposed in the USA in the 1940s, scientists established an optimum of 1 mg fluoride/litre of water. This level was accepted as being the level at which fluoride would be effective at preventing dental decay but which would not cause moderate dental fluorosis.

In the past 5 years, the concentration of added fluoride has been reduced to 0.7 mg fluoride/litre of water in the USA because too many children are experiencing Moderate Dental Fluorosis. Thus the US Health Authorities have been able to move with the times and have acknowledged the causation between too much fluoride and Moderate Dental Fluorosis.

In the 1940s – 1950s, the use of fluoride by dentists was not widespread and it was considered to be safe to add 1mg fluoride/litre drinking water. These days, we are being assailed with rather more fluoride in our environment: fluoridated toothpaste, fluoridated bathwater, fluoridated varnish, fluoridated foods and drinks, fluoridated floss, fluoridated mouthwash, fluoridated dental cement and fluoridated pharmaceutical drugs.

Fluoridated toothpaste is instrumental in causing Dental Fluorosis if swallowed. Unfortunately, according to Rock and Sabieha (1997), young unsupervised children swallow their toothpaste and this, together with swallowing fluoridated water, contributes to Dental Fluorosis. The York Review (2000) estimated the prevalence of Moderate Dental Fluorosis as being 12.5% of the population where the water is fluoridated at 1mg fluoride/litre water and 48% Dental Fluorosis of all types at the same concentration. Even at 0.7 mgF/litre, the estimate is 10% and 42% respectively. Estimates were arrived at by examining all the research on Dental Fluorosis which met the Review’s researchers’ quality checks and criteria. The York Review was commissioned by the Department of Health in 1999, so its conclusions should be respected and not ignored.

Dental fluorosis is damage to tooth enamel and was regarded by the UK Government in 1999 as being a manifestation of systemic toxicity (Hansard, 20 Apr 1999 : WA 158). Seventeen years later, the prevalence of Moderate Dental Fluorosis is bound to be higher because of the increased use of fluoride varnish in schools and dental surgeries. The fluoride varnish will inevitably erode and be swallowed, thus adding to the toxic body burden of this developmental neurotoxin.

Please answer these questions:
1. Has PHE considered reassessing the need to fluoridate drinking water at 1 mg fluoride/litre of water in view of the increased and increasing prevalence of fluoride in a child’s environment? Note that the USA and the Republic of Ireland have both reduced the concentration down to 0.7mg F/litre. Why is the UK lagging behind?

2. Has PHE thought to observe the recommendation of the World Health Organisation and aggregate all sources of fluoride before setting or continuing with the original 'optimum' concentration of fluoride which is currently added to drinking water?

3. Because the application of fluoride varnish is increasing throughout areas of England where small disadvantaged children are being given fluoride treatments, has PHE yet thought to review the need to add fluoride to our drinking water? There can only be one reason for adding fluoride to our drinking water and that is to prevent dental decay in small disadvantaged children and they are increasingly receiving fluoride varnish treatments. Older children, teenagers, adults and those who have no teeth do not have enamel capable of being influenced by systemic fluoride and, according to Childsmile, (http://www.child-smile.org.uk/profession...) permanent teeth are not capable of being damaged by fluoride after the age of 4: “There would also be very little chance of fluorosis, even with two doses given in quick succession as, after the age of 4 years, most of the adult teeth [under the gum] will have already calcified.” The implication is that if the teeth have calcified under the gum, systemic fluoride cannot have any influence on strengthening the surface of the enamel organ either.

4. In fact, the saliva theory is currently favoured by dental professionals and researchers and when saliva comes into contact with teeth, this is a topical effect and not a systemic effect. Thus the original reason for water fluoridation has disappeared. Now, the saliva theory is all very well but when, according to the NDNS 2014, small children only drink one-third of a litre of water a day, they are circulating a mere 0.0067 mg fluoride/litre saliva, this being 224,000 times lower concentration than in toothpaste at 1,500 ppm fluoride. Is UK Government via PHE content to go along with Local Authorities spending Council Tax on ensuring that small children circulate fluoride at a concentration of fluoride which is 224,000 times less than that found in fluoridated toothpaste?

Yours faithfully,

Joy Warren

FOI, Public Health England

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FOI, Public Health England

9 Atodiad

Dear Miss warren

Please find attached Public Health England's response.

Kind regards

FOI Team

Dear Public Health England,

Please pass this on to the person who conducts Freedom of Information reviews.

I am writing to request an internal review of Public Health England's handling of my FOI request 'Concentration of fluoride added to drinking water in fluoridated areas of England'.

PHE is the agent of the Department of Health. Within PHE there are certain Civil Servants, for example Dr Sandra White, who are responsible for defending Water Fluoridation policy. If Dr Sandra White could be persuaded to look at the issue of the concentration of fluoride added to drinking water and to then examine the dosage, she would see that there is more fluoride in a child's environment now than when the 'optimum' concentration of 1ppm was recommended in the USA in the 1940s and 1950s. 1ppm was chosen as being effective against dental decay without causing moderate dental flurosis.

My request for information disclosure contained 4 questions:

1. Why is the UK lagging behind the USA (and the Irish Republic) in relation to reducing the concentration of fluoride down to 0.7ppm in view of the increased and increasing presence of fluoride in a child’s environment?

2. Has PHE thought to observe the recommendation of the World Health Organisation and aggregate all sources of fluoride before setting or continuing with the original 'optimum' concentration of fluoride which is currently added to drinking water?

3. Has PHE yet thought to review the need to add fluoride to our drinking water? There can only be one reason for adding fluoride to our drinking water and that is to prevent dental decay in small disadvantaged children and they are increasingly receiving fluoride varnish treatments. Older children, teenagers, adults and those who have no teeth do not have enamel capable of being influenced by systemic fluoride and, according to Childsmile, (http://www.child-smile.org.uk/profession... permanent teeth are not capable of being damaged by fluoride after the age of 4.

4. Is the UK Government via PHE content to go along with Local Authorities spending Council Tax on ensuring that small children circulate fluoride in their saliva at a concentration of fluoride which is 224,000 times less than that found in fluoridated toothpaste?

It is true that I was not seeking empirical data and if that excludes me from receiving a definitive answer then so be it. However, I have not been able to receive any sensible replies from PHE to my earlier questions relating to policy decisions or their reluctance to re-examine water fluoridation. So I decided to have another attempt via FoI. If this request for a review fails, perhaps the Reviewer would like to suggest which avenue I should go down in order to discover why PHE refuses to review water fluoridation. Currently, I seem to be in a virtual cul-de-sac!

For your information, I am appending below an extract of a report which I wrote for Bedford’s Overview and Scrutiny Committee in early 2016. PHE Bedford’s report to the Committee in 2015 was unable to prove that dental decay had increased 6 years after the temporary cessation of water fluoridation in the Borough. I am concerned that PHE in London might not have seen that PHE report. If, on the other hand, Dr Sandra White has read it, then why is there such a reluctance to re-examine the policy? You may know that Bedford decided against reinstating Water Fluoridation in 2016.

(If pictures and tables do not appear below, please contact me direct on [email address] so that I can resend.)

A full history of my FOI request and all correspondence is available on the Internet at this address: https://www.whatdotheyknow.com/request/c...

Yours faithfully,

Joy Warren

_____________
Note: The York Review (2000) estimated a prevalence of dental fluorosis of aesthetic concern in England as being 12.5% (Table 7.7, p. 38). (The York Review was commissioned by the Department of Health in 1999 so shouldn't the DH and PHE have listened to its own conclusions!

Extract from a report by Joy Warren to Bedford’s O&SC in February 2016 relating to PHE’s Perceptions of Dental Fluorosis (PHE Bedford Report, Paras 5.26-5.28)

1.24 The [PHE] report also provides 3 paragraphs on Dental Fluorosis and attempts to show that this enamel defect is of scant concern. How can it be of scant concern when numerous studies reveal that although TF2 is not as disfiguring as TF3 and TF4, TF2 is widely regarded by teenagers as unacceptable (see Appendix H). Ref: Marshman et al, 2008; Edwards et al, 2005; Hawley et al 1996; Alkhatib et ali, 2004). See 1.28 below for a further discussion regarding TF scores.

1.25 “As fluorosis severity increases (TF2 or greater), the rating of images [by teenagers] and perhaps the level of acceptance declines." (Ref: Mcgrady. 2012)

We have copied below the relevant data relating to Bedfordshire’s survey of Dental Fluorosis (which inexplicably is not part of Bedford PHE’s report) and compared the data with the table for Bedford found in Section 5.26 (p. 24).

1.26 The first thing to note from the 2015 Report is that the term “Dental Fluorosis” is interspersed with the term “white marks”. According to the British Dental Association, PHE and the British Fluoridation Society, Dental Fluorosis (DF) is a cosmetic issue. Attempts have been made in the past by the dental fraternity to make DF sound attractive. Indeed, according to them, there is nothing to be concerned about if your teeth are chalk-white or have attractive white spots. However, their ‘belief’ was blown by Baroness Hayman in 1999 when she stated ““We accept that dental fluorosis is a manifestation of systemic toxicity…” (Hansard 2014/99: WA 158.) Thus, any degree of Dental Fluorosis is too much Dental Fluorosis. No matter the degree, the body is being poisoned.

1.27 Whilst the Bedfordshire data (from which the Bedford data was extracted) shows that 77 12-year-olds were aware that they had significant aesthetic opacities (also known as Mild-Moderate Dental Fluorosis), there is no attempt in the Bedford PHE Report to tell Bedford’s O&S Committee how many Bedford 12-year-olds were included in this figure of 77. We are not even told the number of 12-year-olds who responded with “Yes, I have white marks” although it could be calculated but ... that’s not the point. This data should be provided since it clearly exists. We have to ask why it has not been provided to Bedford’s O&S Committee? Why has important data for Bedford not been divulged?
White marks’ survey: Bedfordshire figures 2008-09. (This table combines data from two tables in the Bedfordshire report.)
Pop. of 12-year-olds in Bedfordshire No. examined Yes, I have white marks No, I don’t have white marks Don’t know if I have white marks No answer Significant aesthetic opacities White marks not significant
5,219 765 130 (17%) 494 (64.6%) 139 (18.2) 2 (0.3%) 77 (10.1%) 156 (20.4%
Source: http://www.nwph.net/dentalhealth/reports...
White marks’ survey: Bedford figures 2008-09 (p. 24 of the PHE Bedford Report)

This data below is contained in the data above – but data on significant aesthetic opacities is missing! Why?

Population of 12-year-olds in Bedford No. examined Yes, I have white marks No, I don’t have white marks Don’t know if I have white marks No answer Significant aesthetic opacities White marks not significant
? 240 ?
19.1% ?
58.9 ?
21.6% ? ? ?

1.28 Significant aesthetic opacities: The conventional classification for dental fluorosis which is used by most dental researchers is the TF Index which describes 9 categories of DF. It would appear that “significant aesthetic opacities” describes the same disfigurement as Mild-Moderate Dental Fluorosis which becomes more unsightly with the passing years when the ‘attractive’ white marks become ugly brown marks. But it could equally apply to TF2. Even if such white marks are not objectionable now when the child is aged 12, as time goes on, TF2 white marks become brown opacities. The brown staining cannot be removed and this implies that it is the underlying dentine which may be stained. If stains can get into the teeth then so too can decay! (See page 15 for the section on dentine bombs and Appendix H for the TF index and Dean Index.). Remediation (i.e. veneers) is not available from the NHS because dental patients have to wait for their permanent to stop growing and this is after the cut-off point for NHS treatment.

1.29 Until we know the definition of “significant” we will be forced to conclude that surveyed children have been worried about fluorosed teeth which are classified as TF2 – Questionable/Very Mild.

Dental Fluorosis

Photographs of Dental Fluorosis by Dr. Hardy Limeback and Dr. Iain Pretty, et al

TF Index of Dental Fluorosis (extract)

1.30 The conclusion in the PHE Bedford Report that “concern about fluorosis is very low” is not corroborated by the Bedfordshire statistics where 765 children were asked specifically about significant aesthetic opacities and where 77 children stated that they had the enamel defect. Moreover, where approx. 10% of the sampled 765 12-year-olds in Bedfordshire had significant enamel opacities, could this have meant that a possible 500, 12-year-olds out of the total of 5219 12-year-olds in Bedfordshire (including Bedford) had significant enamel opacities? How many of the possible 500 children lived in Bedford in 2009?

1.31 “It is clear from the results of this study that participants have a preference for white, blemish-free teeth . . . . As fluorosis severity increases (TF 2 or greater), the rating of images (and perhaps the level of acceptance) declines which is in agreement with earlier work.” (Ref: McGrady, 2012).

1.32 77 (10%) out of 765 children were concerned and ticked the significant aesthetic opacities box. This is not “very low” (10%) and the gloss put on this disfigurement by Bedford PHE is completely unsupportable.

1.33 What is the purpose of this section of the PHE 2015 Report? Why is Bedford PHE trying to minimise the negative impact that Dental Fluorosis will have on these young people when they are adults? (See p. 31 for the Cochrane Review’s Key Results relating to Dental Fluorosis.)

1.34 Throughout the USA, approximately 41% of adolescents have Dental Fluorosis with 3% having moderate and severe DF. However, the percentage experiencing dental fluorosis in fluoridated areas is higher: 70-80%. TF2 scores and higher would, by implication, also be higher. Moreover, it is in the scientific literature that black and ethnic children are more severely impacted by Dental Fluorosis than white children. (Burgstahler, 1965):
“In a survey of children in grades 7, 8 and 9 in Central High School in Grand Rapids, Michigan (1ppm Fluoride) in the 17th year of fluoridation, Russell (1962) reported that 19.3% of the white children of continuous residence had “fluoride opacities” while more than twice this percentage (40.2%) of the Negro children were similarly affected. Among the white children 6.6% had ‘very mild’ fluorosis and 1% had mild fluorosis. Among the Negro children the figures were 9.9% and 4.2% respectively.”
Ref: http://fluoridealert.org/studies/dental_...
Marshall 2004; Locker 1999; Luke 1997

1.35 Dental Fluorosis negatively impacts enamel and the underlying dentine. Fluoride alters the mechanical properties of enamel: fluoridated enamel is harder but paradoxically more brittle due to the incorporation of fluoride into the hydroxyapatite crystal matrix when the teeth are developing under the gum. Fluorosed teeth are difficult to drill and fill so future dental treatment threatens to be more expensive for those affected.
Ref: Fejerskov O, Richards A, DenBesten P. (1996). The effect of fluoride on tooth mineralization. In: Fejerskov O, Ekstrand J, Burt B, Eds. Fluoride in Dentistry, 2nd Edition. Munksgaard, Copenhagen. pp. 112-152. http://cariology.wikifoundry.com/page/De... ; http://fluoridealert.org/studies/dental_...

Dentine Bombs and Fluoride Bombs
1.36 Due to the change in the mechanical properties of enamel, fluoride can be the cause of micro-cracks forming in the enamel, through which bacteria can pass, which can in turn leads to decay beneath the enamel that often cannot be detected by a dentist’s probe. The subsequent result can be what appears to be a very minute amount of decay in the groove of a tooth which hides a ‘bombed-out tooth’ beneath it which is known in dental circles as a ‘dentine bomb’. This is explained below in extracts from Dental Journal articles.

1.37 From Dental Sense : Fluoride bombs refer to large areas of tooth decay in the absence of cavities. … if fluoridated enamel is stressed repeatedly during parafunctional states, microcracks can appear, propagate and in turn “open the door” for cariogenic bacteria to access the organic component of teeth resulting in degradation of dentine and undermining of enamel, similar to traditional models. The difference being that teeth exposed to fluoride during formative years will not cavitate as early and the same stresses that caused the microcracks continue to fuel the spread of the carious lesion. Conceivably, therefore, fluoridation may help prevent dental caries caused by “acid attack”, but equally may now mask breakdown associated with “crack attack”!
Ref: http://www.dentistmidland.com.au/dental-...

1.38 From Shore Dental : There have been some unintended consequences of the introduction of fluoride into the water. The one of relevance to this document refers to the way in which decay operates within a tooth. Fluoride causes a tremendous increase in the hardness of the enamel (a decrease in the solubility of the enamel in response to an acid attack caused by plaque). Decay does not become so evident to the dentist as it did previously. Instead of the decay forming an open cavity which was easily visualised and easily felt by a sharp metal probe, decay now tends to start inside a tooth. This is because the bacteria and saliva can get through at the very fine crack on the surface (we call this the fissure) and commence decaying at the softer portion of the tooth inside called the dentine. As a result of this, the decay can go undetected for many, many years and ends up in what dentists refer to now as a ‘fluoride bomb’. The inside of the tooth is completely decayed and the outside looks fairly normal – sometimes there is a slight discolouration evident through the enamel, but often the decay cannot even be felt with a sharp metal probe – this is scary stuff to dentists because for decades we have relied on diagnosis of decay by feeling the softening of the enamel with a metal probe. We can no longer do this.
Source: https://www.shoredental.com.au/

Ref: http://www.fluorideresearch.org/404/file...

1.39 Could this be the reason why some large cavities materialise very quickly where before there seemed to be none?
--------------End of extract

Since the tables are no longer formatted and photographs are missing, please request a resending of the above extract via email. My email address is [email address]. Thank you.

FOI, Public Health England

We acknowledge receipt of your email and request for information, which will be treated as a request for information under statutory access legislation.

Please note that requests under the Freedom of Information Act and the Environmental Information Regulations (EIRs) will receive a response within 20 working days from the day following the date of receipt of your request.

If the request is for your personal data (i.e. a Subject Access Request) under the Data Protection Act, then we will respond within 40 calendar days.

Public Accountability Unit
Public Health England
[Public Health England request email]
Tel: 020 8327 6920 
www.gov.uk/phe   Follow us on Twitter @PHE uk

FOI, Public Health England

1 Atodiad

Dear Miss Warren

Please find attached Public Health England's response to your request for information.

Kind regards

FOI team

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