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A CRITIQUE OF THE MRC REPORT, 2002.

A new collaboration - but the same old story

One look at the Medical Research Council’s (MRC) Working Group (see Appendix) on water fluoridation membership list and you immediately realise that there was little chance of impartiality on the final outcome.

Hypocrisy and spin

It was as early as the ‘Lay Summary’ (Page 2) of the Final Report that the bias of the Group was exposed. It was falsely stated that:

“The York review, published in September 2000, confirmed the beneficial effect of water fluoridation on dental caries (cavities).”

This ridiculous claim was also repeated on Page 4 (Chapter 1.1, para. 2). A similar claim was also made on Pages 18 and 19. What Professor Sheldon (Chair of the ‘York review’) actually said of the findings was that:

“… the quality of the studies was generally moderate …”[1]

“Moderate” evidence doe not constitute a confirmation – it only merits a suggestion. This is supported by the final report of the York Review (Page 12 and the Executive Summary) which clearly states:

“The best available evidence suggests that fluoridation of drinking water supplies does reduce caries prevalence, both as measured by the proportion of children who are caries free and by the mean change in *dmft/DMFT score. The studies were of moderate quality (level B), but of limited quantity. The degree to which caries is reduced, however, is not clear from the data available.”

*dmft: mean number of decayed, missing or filled teeth in the deciduous dentition (first teeth) DMFT: mean number of decayed, missing or filled teeth in the permanent dentition. (MRC).

Ironically, the MRC did admit on Page 18 that:

“In particular, many studies had failed to take sufficient account of confounding factors.”

Furthermore, and although Prof. Sheldon claimed that there was some evidence that ”water fluoridation is effective at reducing caries”, the claim was based on just four dubious studies.[2] At least one of these studies was considered to be open to bias, one was very poor and all four did not control for confounding factors. This is hardly a sound basis for claiming that water fluoridation reduces dental caries.

The situation is exacerbated on page 8 under the Chapter title: ‘2.3.2 Presenting to the public the inevitability of uncertainty in research findings’.

"In an era when ‘science’ is under increasing public and political scrutiny, and in which the media can generate unrealistic and unachievable expectations of certainty or ‘proof’, there is a need to communicate honestly and openly about the levels of certainty that can and cannot be inferred from research findings. Uncertainty is an inherent feature of science and medicine, but this is a concept that seems not to be well understood by the public.”

Two significant points are raised. The first is: “a need to communicate honestly and openly” and the second is: “Uncertainty is an inherent feature of science and medicine”.

These two statements do sit easily together. We are informed by the MRC’s Report that the effectiveness of fluoridation is “confirmed”. If “uncertainty” is an “inherent feature of science and medicine” then how can the effect of water fluoridation be proven? It can’t and therefore the MRC should “communicate openly and honestly” and admit as much – but they haven’t.

Another nail in the MRC’s coffin is the further claim in Chapter 2.3.3. It states:

"It is important to explain simply the concept of differing ‘strengths’ of evidence that can be derived from different types of research design, as well as the changing methodological standards that have been used in research over time. For example, it is unrealistic in many fields to expect a study carried out in the 1970s necessarily to conform to the methodological standards judged appropriate in the 2000s. Also, the quality of research published on the Web and in other non-peer reviewed sources is unlikely to match that of research published in the standard scientific journals, and therefore generally carries little weight. Some members of the public (and many health professionals) may not yet be used to these concepts.”

In the four studies used to ‘confirm’ the benefits of fluoridated water, one study was published in 1965, two in the eighties (1981, 1984), and one in 1997. Brown’s 1965 Brantford / Stratford / Sarnia (Canada) study,[2] as well as being condemned as being open to abuse, is 37 years out of date. Beals’ 1981 Scunthorpe / Corby, (England) study[2] is also outdated and open to question. These two studies alone constitute 50% of the claim that fluoridated water is efficacious.

Rubbing salt into the wound

The MRC’s Report is not just about politicized science, there are some very salient and truthful admissions. One of the first is the acceptance that:

"There has been limited dialogue with the general public on the fluoridation issue.”

So who’s fault is this? Water fluoridation schemes fall under two broad categories concerning consultation. The first is that any schemes not agreed prior to the enactment of the 1985 Water (Fluoridation) Act were subject to public consultation. Schemes agreed before this time could proceed without any further consultation.

Both scenarios have been open to abuse by Health Authorities (HA[s]). In Worcester, the HA had already a pre-existing agreement to extend water fluoridation but did not consider it worthwhile or prudent to indulge in further consultation. It was stated that consultation had taken place in the 1970s and the Director of Public Health did not consider it necessary to indulge in any further dialogue. Essentially, the pre-existing agreement was sufficient to defeat any attempt to raise more contemporary concerns and issues.

Similarly, post-1985 schemes which were subject to consultation, were equally prone to abuse. Examples of HAs consulting with local authorities have demonstrated quite clearly that the consultation process is merely cosmetic. This is because consultation is not binding and regardless of the evidence presented against fluoridation, or the opposition of the local authorities involved, some HAs have abused their power and have attempted or proceeded with water fluoridation schemes against the will of the local authorities and their populations.

The MRC have gone some way to mitigating the situation by highlighting the following observation (Chapter 2.3.4: Public perception of fluoridation):

“A study with focus groups in three non-fluoridated areas of England (Hounslow, Leeds and Oldham) indicated that members of the public wish to be informed of water fluoridation plans but do not see themselves as being appropriate arbiters of decisions about implementation (Lowry et al., 2000). However, even where the public does not wish to make decisions, this does not imply that this opportunity should be withdrawn.”

Chapter 2.3.5: ‘Information needs’ adds:

“Listed below are some specific issues that could usefully be communicated to the public about water fluoridation:

  • The actual coverage of water fluoridation in the UK at present (many assume it is more widespread than it is)
  • The consequences of not preventing dental caries – costs, morbidity and mortality
  • The strength of evidence on the efficacy of (and problems associated with) alternatives to water fluoridation
  • The nature, effects and degree of aesthetic impact of dental fluorosis

The common sense view is that benefits should outweigh the risks (Chapter 2.3.6: What is most important to the public?). Both preventive benefits and potential harms must be set out clearly and consistently to avoid confusion and mixed messages to the public. Of course, the public may view the potential harm as more significant than the benefits, even though the numbers involved might be much smaller; people may feel that they are being asked to compare apples and oranges.”

The MRC appear to be ‘leading the horse to water’ but trying to imply that it should not be encouraged to drink unless it really is thirsty. By indicating that the general public should be informed of potential fluoridation schemes, but also indicating they may not wish to vote on the issue, merely reinforces what some HAs have been doing for quite some time – requesting implementation of fluoridation without giving the local population the final say.

It should also be questioned on who should be allowed to ‘educate’ a local population when fluoridation is proposed. Because it is a contentious issue it should be permitted for both opposing camps to present their arguments. It is feared, however, that the pro-fluoridation HAs may try to deceive the general public by pretending to present a ‘pro’s and con’s’ argument. This must not be allowed to happen but it has been demonstrated on many occasions that those who claim to be in the best position to decide are usually the HAs who will almost exclusively rig their argument to justify their decision to fluoridate.

One of the “specific issues” which has been subject to the biased views of the pro-fluoride lobby is the following:

“The consequences of not preventing dental caries – costs, morbidity and mortality”

Emotional blackmail and the inducement of financial gains have been employed on a regular basis by the pro-fluoride lobby without any regard to the accuracy or validity of their arguments.

As for ‘benefits and risks’, there is no argument. Because water fluoridation is an absolute measure, those who are sensitive to the chemical will not be able to escape it’s consequences. Where the risk is accepted, it must be for the individual to chose whether or not they wish to supplement their diets with fluoride. Mass medication (or supplementation) of a population would be a reckless step to take where any risk exists.

The Chapter concludes with a mention of opinions based on “outrage” rather than “the magnitude of the potential risk”. Yes, water fluoridation is a volatile issue that does sometimes give rise to heightened emotions. But it is not so much the pros and cons of fluoridation as the issue of trust and civil liberties.

Because the ‘establishment’, the government, some dentists and their unions, and some doctors sometimes resort to dishonesty to defend fluoridation, it merely serves to ‘raise the hackles’ of those who feel threatened by water fluoridation. If those who distort the truth on water fluoridation were to be completely open and honest then there would be less “outrage”. Unfortunately, the pro-fluoride lobby have on many occasions not shown any desire to be sincere and this is the main cause of public outcry.

Improvements in dental health since 1973

In Chapter 3.2: Sources of fluoride exposure, it is stated:

"... in the 1970s fluoride started to be added to toothpastes and by 1978 96% of toothpaste on the market contained fluoride, usually at a concentration of 1000 to 1500ppm (though it should be noted that in the UK lower fluoride toothpastes containing about 500ppm fluoride are now available for use by children).”

It is true that between 1973 and 1993 that dental health has improved dramatically in England and Wales, by (commonly) around 50%-75%.[3]

So how was this achieved mostly without the alleged benefit of water fluoridation? Whatever the impact of toothpaste one thing is certain – attitudes to dental health have changed and this will also have made some contribution to the observed improvements.

The MRC also observe on Page 18 (4.1.2: Implications):

"The reduction in sugar consumption in UK children since the 1960s and the introduction of fluoride toothpaste in the 1970s led to substantial reductions in dental caries (Todd & Dodd, 1985). However, these reductions were not uniform and led to widening social inequalities in children’s dental health.”

And on Page 21:

"Diets of more socially deprived children are more caries conducive than diets of more affluent children, and more affluent children brush their teeth with a fluoride toothpaste more often than do more socially deprived children (Hinds & Gregory, 1995).”

The salient point is this: if dental health can be improved dramatically without the use of fluoridated water, and one scheme in Lanarkshire, Scotland in recent years has demonstrated this, then how much impact would fluoridated water have on a community? One of the concepts employed in Lanarkshire was to reduce the consumption of sugary products.

It is also distinctly possible, and in some cases probable, that when fluoridation has been introduced in certain communities, efforts outside of fluoridation have been employed to improve dental health. Brown’s comments on his 1965 study certainly implied this:

"... the recordings so far obtained indicated both a high treatment level and an apparently better oral hygiene status of the Brantford children when compared with the controls, and it is therefore suggested that caution should be exercised in the interpretation of the rates shown. The lack of a prefluoridation survey on a comparable basis is a further limiting factor in interpreting the results.” [Ecologist, vol. 16, no. 6, 1986]

Geography and ethnicity

No one would argue that there are wide variations in dental health throughout the UK. Ethnic origin will also have some impact, especially where there are relatively large population concentrations.

The MRC’s slant on this issue is:

"The British Dental Association has suggested that water fluoridation should be targeted to high risk communities in order to try to reduce the widespread geographical and social inequalities in dental health.”

What appears to have been missed, despite its glaringly obvious presence in every BASCD annual study [4] of dental health, is that strong geographical variations exist between similarly socially deprived non-fluoridated areas. For example, while some communities in the North West of England may have high levels of tooth decay, there are some similarly deprived communities in the Central London area with much less ‘dmft’. Ethnic variations in local populations will also add another dimension to geographical variations.

The MRCs “Research recommendations” (Chapter 4.1.3) ask for “further studies”. This is a dangerous proposition. There are already enough fluoridated communities in which to analyse the effects of fluoridation. It would also be possible to de-fluoridate certain communities and compare them to local populations where fluoridation still exists. It has already been demonstrated in other studies that where fluoridation is stopped, there is no real change in the dental health of such communities.

In a nutshell, the MRC are just using the “further studies” argument to bring in more fluoridation schemes by stealth – not that this has come as a surprise to those who are more informed about the measure.

Fluorosis

One of the oldest tricks in the book is to provide an opposite argument to a proposition which cannot be readily disproved.

This is especially true of fluorosis with the MRC making the following comment (4.2.2: Research recommendations):

“There are discrepancies between the dental fluorosis data reported by the York Review and recent data from the UK and Europe.”

The MRC are quite happy to misrepresent the York Review by making misleading claims about the efficacy of fluoridation and not giving due consideration to any opposing arguments. But when it comes to fluorosis, where evidence showing that the use of fluoride is clearly linked to the condition, the MRC attempt to defuse the situation by trying to undermine the Review’s evidence.

There is also the question of the ‘meaning’ of fluorosis. The MRC appear to propose that it is merely a cosmetic issue.

"Further studies should determine the public’s perception of dental fluorosis with particular attention to the distinction between acceptable and aesthetically unacceptable fluorosis.”

Prof. Sheldon of the York Review stated:

“The review found water fluoridation to be significantly associated with high levels of dental fluorosis which was not characterised as 'just a cosmetic issue'.”[1]

It has been said that the teeth are the ‘windows of the skeleton’ and that the presence of fluorosis can suggest possible skeletal problems at some later stage of life. That is unless the dental fluorosis is so severe that it may already be accompanied by some form of skeletal disorder (as seen in India).

Regardless of the severity of dental fluorosis, it still represents a warning sign for those affected and is NOT just a cosmetic issue.

There is also the issue of psychological and physical trauma. Children who are too afraid to smile because of their stained teeth or children who’s permanent dentition is pitted and damaged by fluorosis are just two examples. This is of course not to mention the high cost of repairing or cosmetically altering teeth damaged by fluoride.

The only reasonable conclusion is that the MRC’s statement on “acceptable” fluorosis is both disgraceful and insulting to those afflicted.

Nailing their colours to the mast

In ‘Chapter 4.3: Effects of social class’, the MRC show their true nature:

“Water fluoridation has advantages over other possible caries preventive measures in that it reaches everyone in a community who is on a public water supply. It is therefore seen as an equitable public health measure, and there has been considerable interest in the question of whether water fluoridation benefits most those people at greatest risk of dental caries, ie the more deprived members of a community. If so, water fluoridation could be an important means of reducing inequalities in oral health.”

The MRC make it quite clear of their support for fluoridation. This is not surprising since the Working Group is so heavily loaded with established pro-fluoridationists. The consequences are that any further research projects will be distorted by misguided preconceptions of the value of water fluoridation.


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