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SCIENCE SECTION

Sutton 8.3

CRITICISMS AND COMMENTS (Continued)


MR J. FERRIS FULLER

Apart from the reviews already quoted above, the only published criticism known to the author is that contained in the Book Reviews section of the January 1960 issue of the New Zealand Dental Journal. This was contributed by MR J. FERRIS FULLER, a member of the Dental Research Committee of the New Zealand Medical Research Council and a member of the Fluoridation Committee of the Department of Health, whose submissions to the New Zealand Commission of Inquiry (1957) are mentioned in over twenty paragraphs of its report.

"Everyone is out of step except our Albert," or so the author would have us conclude. Altogether an extraordinary book; clever but unfortunate; skilfully contrived and yet-stripped of its finery-rather slender. It could be ignored if the matter rested within the Sciences; but since by the very nature of the subject it takes us into the public forum, some of the errors must be stated.

Part 1 of Fluoridation: Errors and Omissions in Experimental Trials (Chapter 19 here) is a reprint of a paper by Sutton and Amies (see footnote on page 136) that appeared recently in the Medical Journal of Australia criticising the Brantford-Sarnia-Stratford study in Canada(52). But the authors have omitted to read the literature(53), and their criticisms therefore are not based on the known facts. This is a serious matter especially when the comments come from two critics who exalt themselves above fellow scientists of at least equivalent status in other parts of the world. They accuse the Canadian workers of failing to devise a randomisation procedure that would eliminate bias(54), of deliberately omitting vital information in some of the tables(55), and finally of displaying bias in the presentation of results(56). Their comments are based on a report of the Ontario Department of Health (1956) to the Ontario Minister of Health, a report obviously written in simple abbreviated terms for public consumption(57). Sutton and Amies failed to read two official publications readily available(58), namely, a 51-page booklet "A suggested methodology for fluoridation surveys in Canada" and the 35-page detailed report of the Department of Health and Welfare, of November, 1955 These two booklets together show that great care was taken to introduce a well-designed randomisation procedure(59), that examiner variability was eliminated as far as humanly possible by the employment of one examiner only throughout the whole period of the study(60), and that the information alleged to have been omitted is in fact shown in detail in the tables in the 1955 report(61), together with the standard error for each of the indices used. In short, the more important criticisms that appear so damaging are in fact without foundation. Thus, when the authors say that "what must be eventually a statistical study does not appear to have been designed as such" and "no attempt at statistical evaluation has been considered" their comments are absurd and, indeed, irresponsible(62). The full official report on the Brantford study was available in New Zealand, incidentally, when the Commission of Inquiry held its hearings(63), and three of its tables are included in the published report of the Commission.

In Part 2 of the book Sutton continues in the same vein. He complains that misleading comments are made in some reports, yet his own book contains many misleading statements. For example, he claims that a proper evaluation of examination errors at Grand Rapids has not been carried out(64), and he doubts the accuracy of caries attack rates in test and control areas because X-ray examinations were incomplete or absent(65). It is significant that he omits to refer to a report by Hayes, McAuley, and Arnold published in the U.S. Public Health Report in December, 1956, which is a key reference in this subject(66). This report met the specific point that "some observers have suggested that X-rays are essential to determine the efficacy of caries control measures" and an investigation was undertaken "to determine whether or not supplementing direct observation with X-ray examinations would affect the conclusions based on direct observation alone." The conclusion was that supplementary X-ray examinations supported the clinical findings and did not change the basic observation that substantial decreases in dental caries occurred during the test period. The very standard errors that Sutton demands for a proper statistical evaluation were available in this report(67). He quotes a subsequent (1957) paper by McAuley that suits his book and, in the light of his criticisms and allegations, this makes the omission of any reference to the 1956 report more damaging(68). To borrow his own phrase, omissions of this nature render his work "open to doubt." Sutton criticises his overseas colleagues for their inability to examine children in control towns prior to fluoridation(69). With personal experience of a study of this nature he would appreciate that where on the one hand the interests of a large number of people and their local bodies and institutions are concerned as compared with only one or two examining personnel on the other, it is almost impossible to operate a plan to the exactitude dreamed of at the statistician's desk. In any event, the criticism is rather meaningless as far as the Grand Rapids study(70) is concerned when we realise that the baseline examination in the control city of Muskegon showed that caries prevalence in that city is of the same order as in Grand Rapids.

In attacking the Evanston-Oak Park study, Sutton bemoans the lack of information about the design of the study and phrases such as "It is not clear...", "It is not understood...", (It) was not stated" ... give the lead to questions and speculations that follow. But why not adopt the simple expedient of writing to the workers concerned and so finding out instead of speculating? This attitude is typical of the book(71). And typical also is the quibbling over details that do not detract one iota from the part that fluoridation has played in these areas in reducing dental decay(72). "The total tooth surfaces considered ... should be 58,325, not 58,352" says the author, and also ... "the mean of these values for 1946... is 150.09, not 149.76"(73). Dear me, Dr Sutton, how dreadful.

And then we come to the Newburgh-Kingston study. Prominence is given to the different composition of the waters at Newburgh as compared with the control city of Kingston(74), and this is cited as the reason why the latter is unacceptable as a control. But once again Sutton omits any reference to a key report, that by Dean, Arnold, and Elvove of August, 1942, listing caries prevalence rates in communities where the variables in the domestic water mentioned by Sutton varied to a greater degree than between Newburgh and Kingston without caries prevalence being markedly affected(75).

The author complains of bias in the manner in which some results are presented but, as can be seen, he displays bias himself in the choice of articles he quotes(76) and in his omission to read others. It is not surprising, therefore, to see him fall into the familiar pattern of the anti-fluoridationist. Those who question fluoridation are given the familiar title of "eminent authorities," a distinction not afforded anyone else(77). It is surprising, however, to see him serve his ends by quoting Feltman's study on the use of fluoride tablets. This study lacks the very control that one would expect Sutton to consider essential(78).

As one would expect, there are no bouquets for the New Zealand Commission of Inquiry, one complaint being that "no mention was made of the employment of a statistician to assist its members in evaluating numerical data." Had the author inquired, he would have been told that the Professor of Biochemistry on the Commission was well versed in biometrics, and that scientific witnesses quickly discovered that tables were unacceptable unless they contained complete details including standard errors, so that he could evaluate data statistically for himself and the Commission(79).

Finally, a warning to those reading this book, lest they be misled by the polemics and the array of figures. Please note that Sutton's conclusions in part 2 (which forms the greater part of the book) are confined to variations in the prevalence of dental decay in control cities and not to the cities where fluoride has been added(80). What of the places where fluoridation has been adopted? Sutton does not dispute the fact that the prevalence of dental decay has been substantially reduced in the fluoridation cities of Grand Rapids, Newburgh, Brantford, and Evanston(81), nor does he mention that these good results have been confirmed by several independent studies in the U.S.A., and also in Tasmania, Brazil, Japan, Germany, Sweden, and at Hastings in New Zealand(82). The validity of the results from Hastings, incidentally, has been checked by the Applied Mathematics Laboratory of the New Zealand Department of Scientific and Industrial Research(83).

The anti-fluoridationists will rejoice with fresh ammunition to replenish their stocks; but it is unlikely that this work will serve any useful purpose in scientific circles despite the author's rather pretentious hopes. The performance is almost as old as Time: "The mountains are in labour, there will be born a ridiculous mouse," said the ancient poet.


Commentary on the Review by Commentary on the Review by Mr J. Ferris Fuller

Webmaster's note: As published in Dr Sutton's book, the first note (62), is given priority in this commentary. Some of the following points are also given out of synchronicity.

(62) The charge made by Mr Fuller that ?their comments are absurd and, indeed, irresponsible? will be considered first, partly because of its serious nature and partly because it sets the standard for his criticisms.

This charge is made by misquoting parts of two sentences (para. a, p. 4). In the second misquotation the word 'comprehensive' was omitted by Mr Fuller, thus completely distorting the meaning of the original sentence.

Fortunately, the fact that Mr Fuller gives several other 'quotations' from the first edition which are not completely accurate permits the interpretation that the omission of the word 'comprehensive' is due to Mr Fuller having read the monograph only superficially prior to publishing his review. If this is not the case, the more unfortunate conclusion must be fared: that he deliberately made this omission in an attempt, by the use of misquotation, to discredit the statements of those whose findings contradict his own beliefs.

Despite the fact that a study of Parts One and Two of this monograph will show the true nature of most of the remaining points raised by Mr Fuller, in order to avoid the possible suggestion that the objections which he raised have not been refuted, some comments will be made on them.

(52) Part One mentions the experimental trials which have been conducted in Brantford, Canada, and in Grand Rapids, Newburgh and Evanston, U.S.A. (p. i). The comments made in it were not confined, as this reviewer infers by his comments and by here ignoring the other studies, to 'the Brantford. Sarnia-Stratford study in Canada'.

(53) In regard to the remark of Mr Fuller that 'the authors have omitted to read the literature' it may be noted that the brief paper (Part One), which he is criticizing in this paragraph of his review, contains references to seven of the original papers which deal with the caries rates from these studies-more than were mentioned in the entire 'bibliography' of the report of the New Zealand Commission of Inquiry (1957).

(54, 59) Mr Fuller said 'They accuse the Canadian workers of failing to devise a randomisation procedure that would eliminate bias'. The original statement (p. i) refers to 'bias on the part of the examiners' and is not restricted to the studies conducted by 'the Canadian workers'. This reviewer says (59) that 'These two booklets together show that great care was taken to introduce a well-designed randomisation procedure'. However the only randomization procedure mentioned in these booklets was related to the sampling process and was used to determine whirls children should be included in the study-it had nothing to do with the elimination of examiner bias. In order to eliminate such a bias it is necessary that the examiner does not know whether each of the children he is examining belongs to the test or to a control city (p. 9). As the examinations in Brantford and its control cities were conducted at different times (p. 43) it is obvious that suitable precautions were not taken to eliminate examiner bias.

(55) The only omissions of information from tables which were mentioned in Part One (p. 4) were the printing of dashes in the Ontario Department of Health Report (1956). Care was taken (p. 4) not to make the suggestion that these Canadian workers were 'deliberately omitting vital information in some of the tables', but Dr Grainger's remarks (Item nine; 43) indicate that the omission of these figures from the Ontario Department of Health Report (1956) was deliberate.

(56) As these omissions were made deliberately, the accuracy of the statement, made on page two of this monograph, that ?Bias is suggested by the presentation of some results?, is confirmed.

(57) In considering the studies in Brantfocd, reference was made to two of the original papers as well as to the figures contained in the tables of the Report of the Ontario Department of Health (1956). This Report was 'A Report to the Minister of Health' and was 'Prepared upon his request by The Division of Medical Statistics' — it was not, as Mr Fuller submits, written 'for public consumption'. Even if it had been, does he suggest that basic figures presented 'for public consumption' should be different from those shown to any other class of reader?

(58) Thanks are due to Mr Fuller for drawing attention to this 1955 booklet of Brown, for it was not realized that two slightly different reports, both termed '1955 Report', were issued from the Department of National Health and Welfare study in Brantford. Reference has already been made to this booklet (Brown, 1955) when discussing Item 13 of Dr Grainger's review (48).

(59) See (54)

(60) Mr Fuller says that reports from the National Health and Welfare study in Brantford show ?that examiner variability was eliminated as far as humanly possible by the employment of one examiner only? However, within-examiner variability remains, and (p. 2) neither withinnor between - examiner variability was estimated in this or any of the other studies considered.

(61) Mr Fuller does not specify the 'information alleged to have been omitted' to which he refers here. As he is speaking of Part One, it is assumed that he means the statement made (p. 2), in regard to the five trials considered, that 'The importance of random variation in the D.M.F. rate (decayed-missing-filled permanent teeth rate) does not appear to have been recognized, or else it has been ignored.' (Other 'omissions' have just been considered under comments 54, 55 and 60).

In 'the tables in the 1955 report' (Brown, 1955), mentioned by Mr Fuller, the mean caries rates and the standard errors of the mean rates were shown, with notations which indicated the 'levels of statistical significance' (Similar data were shown by Brown et al., 1953, 1954b.). In the test city, nine out of the twelve ?Inter-Year? changes in the D.M.F. rates were said to be significant. However, the strange result was indicated that most of the changes in the control cities were also said to be significant (Brown, 1955).

In Sarnia, six out of twelve, and in Stratford, no fewer than eight out of nine changes between successive examinations were said to be significant (ten of the fourteen significant changes in these control cities being indicated as being at the three standard error level). In the first '1955 Report' (Brown, 1955) these changes in the caries rates in the control cities were mentioned, but no reference was made to the fact that most of them were considered to be significant. And as was mentioned (comment 48) in referring to Dr Grainger's Item thirteen, in the second ?1955 Report? (Brown et al., 1956) all mention of these changes was deleted.

(62) See beginning of this commentary

(63) Mr Fuller said that ?The full official report on the Brantfnrd study was available in New Zealand, incidentally, when the Commission of Inquiry held its hearings? (in 1956-7). In that case, and in view of the importance that he appears to attach to this 1955 booklet of Brown (53, 58-61), it is surprising that, as recently as 1959, he ignored it when giving a lecture to the New Zealand Institution of Engineers (Fuller, 1959). On that occasion he said: 'In this age group there has been a 69% reduction in dental decay. The enamel of the teeth of these children has developed under the complete influence of fluoridation and we have a situation the same as that found at Sarnia [air], a situation that verifies the caries/fluorine hypothesis' (Fuller, 1959).

This '69% reduction in dental decay' was shown in the 1954b report of Brown et al., but this very impressive result was a transitory one (pp. 46-7). The chart depicting the D.M.F. rates in this study, which was shown to the Institution, was also taken from that report. Why did Mr Fuller rite the most favourable result from this study and ignore the final report (the booklet by Brown, 1955) which shows that, in these children in Brantford, there was considered to be a highly significant rise in the caries rate during the final year of the study?

(64-7) In Part a of the book Sutton continues in the same vein. He complains that misleading comments are made in some reports, yet his own book contains many misleading statements. For example, he claims that a proper evaluation of examination errors at Grand Rapids has not been carried out, and he doubts the accuracy of caries attack rates in test and control areas because x-ray examinations were incomplete or absent(65). It is significant that he omits to refer to a report by Hayes, McAuley, and Arnold published in the U.S. Public Health Report in December, 1956, which is a key reference in this subject(66). This report met the specific point that 'some observers have suggested that x-rays are essential to determine the efficacy of caries control measures' and an investigation was undertaken ‘to detemine whether or not supplementing direct observation with x-ray examinations would affect the conclusions based on direct observation alone.’ The conclusion was that supplementary x-ray examinations supported the clinical findings and did not change the basic observation that substantial decreases in dental caries occurred during the test period. The very standard errors that Sutton demands for a proper statistical evaluation were available in this report(67).

Comment. Mr Fuller seems to suggest that(64) examiner errors for the Grand Rapids study were given in the paper of Hayes, McCauley and Arnold (1956)-this is not the case. In speaking of that paper, he stated (67) that ‘The very standard errors that Sutton demands for a proper statistical evaluation were available in this report.’ In the first place, standard errors were not demanded, indeed they were not even mentioned in the discussion on the Grand Rapids study.

Secondly, the paper by Hayes et al. (1956) deals with clinical and X-ray examinations made on small numbers of children, from 'four selected schools', in 1946, 1947 and 1953. The children were grouped into three age ranges-five to seven, eight to ten, and twelve to fourteen years. Out of the 11,012 ‘continuous resident’ children of those ages examined in Grand Rapids in those three years, only 736 (less than seven per cent) were X-rayed and included in this study.

This paper showed the caries rates as D.M.F. permanent teeth per child for only the age range of twelve to fourteen years, a range which was not used in the other reports from the Grand Rapids study (Dean et al., 1950; Arnold et al., 1953, 1956). Hayes et al. said that ‘Left and right posterior bite-wing radiographs were made for every pupil. For each fourth-grade child (8-10 years of age), one anterior bite-wing X-ray was made to show the central incisor teeth’. However, despite that statement, they did not publish any results for the premolars, canines, and incisors of children under the age of twelve years.

The three main reports from Grand Rapids (Dean et al. 1950; Arnold et al., 1953, 1956) were concerned with two types of caries rate: the D.M.F. permanent teeth per child and the d.e.f. deciduous teeth per child at each year of age, from four to thirteen years for the deciduous teeth and from six to sixteen years in the case of the permanent ones. None of these rates, nor their standard errors, were shown by Hayes et al. (1956), so that this study was disregarded. It is clear, therefore, that Mr Fuller's suggestion(61), that the standard errors for these Grand Rapids reports were shown by Hayes et al. (1956), is incorrect and misleading.

Mr Fuller stated(65) that the author ‘doubts the accuracy of caries attack rates in test and control areas because x-ray examinations were incomplete or absent.’ This remark refers to the statement made on page sixteen: that the lack of X-ray examinations ‘must throw considerable doubt on the accuracy of the caries attack rates’. This remark is borne out by results published by Blayney and Green (1952) and by Ast et al. (1956). Also, in the paper cited by Mr Fuller (Hayes et al., 1956) it was stated that ‘The combined technique, direct observation plus bite-wing roentgenography, consistently yields a higher estimate of caries prevalence than direct observation alone’. This remark, far from disagreeing with the statement made on page sixteen to which Mr Fuller takes exception, in fact confirms its accuracy. Mr Fuller(66) is confusing two different matters: assessment of changes in caries rates and accuracy of caries rates. He says that it is ‘significant' that no reference was made to the paper by Hayes et al. In this, attention was drawn to the fact that observers had ‘suggested that X-rays are essential for dental surveys designed to determine the efficacy of caries control measures’. In order that the results from the Grand Rapids study, which were based essentially on clinical examinations, could be regarded as reliable, it was necessary to establish that the absence of Xray examinations did not invalidate the findings. The aim of the investigation by Hayes et al. was to determine whether different conclusions regarding changes in caries rates in a study would have been reached if each examination had been supplemented by an X-ray assessment instead of using clinical examination methods alone. This is a different matter from that of the accuracy of caries rates which was mentioned in comment (65) and which was the subject under discussion in the second paragraph of page sixteen.

(68) He quotes a subsequent (1957) paper by McAuley that suits his book, and, in the light of his criticisms and allegations, this makes the omission of any reference to the 1956 report more damaging. To borrow his own phrase, omissions of this nature render his work 'open to doubt.'

Comment. Mr Fuller refers to a 1957 paper by McAuley'. It is thought that he means the 1957 paper of McCauley and Frazier which reports on a caries survey in Baltimore. This paper was mentioned because it provided a recent example demonstrating the marked differences in caries rates which may be attributable to examiner variability (p. 9), and because it provided a recent opinion which had a bearing on the action of fluorides (p. 8). Mr Fuller refers to 'the omission of any reference to the 1956 report' of Hayes, McCauley and Arnold. Although a photostatic copy of that report was obtained, prior to preparing the comments on the Grand Rapids trial (pp. io-i5), the data given in it were not mentioned for the simple and, it would have been thought, obvious reason that the type of data considered in this monograph is not mentioned by Hayes et al. (1956) (see comment 67). Therefore it is ludicrous to refer to this omission as 'damaging' and as rendering the work 'open to doubt.'

(69) Sutton criticises his overseas colleagues for their inability to examine children in control towns prior to fluoridation. With personal experience of a study of this nature he would appreciate that where on the one hand the interests of a large number of people and their local bodies and institutions are concerned as compared with only one or two examining personnel on the other, it is almost impossible to operate a plan to the exactitude dreamed of at the statistician’s desk.

Comment. The incorrect statement (pp. 64-5) of the United Kingdom Mission (1953), that ‘Before fluoridation is started the teeth of the children in both [test and control] towns are examined in detail’, was criticized but not the ‘inability to examine children in control towns prior to fluoridation.’ Mr Fuller suggests that the failure of these workers to conduct prefluoridation surveys in the control cities was due to their ‘inability’ to do so. It will be recalled that the consequences of this failure were particularly obvious in the Evanston trial (pp. i6-si; Fig. 3, p. 22). As Mr Fuller must be aware, in his own country there was a similar failure to conduct an examination in the control city of Napier prior to fluoridating the water supply of Hastings. In the first report from that project (Ludwig, 1958) the caries attack rates in Napier were not published, but it was stated that 'the two cities were not comparable'; as a result, the original plan of this project, to use Napier as the control city, was abandoned.

The Dental Health Division and Research Division of the (Canadian) Department of National Health and Welfare (1952) said that, using only one examiner, ‘the examination of, say, 1,600 children spread over, say, 20 schools can be accomplished in a matter of, at most, 4 weeks, including follow-up.’ Therefore it is obvious that it was not a question of their ‘inability to examine children in control towns prior to fluoridation’ but of a lack of appreciation of the necessity for such a procedure (p. 65). If this necessity had been recognized, it would have been illogical to jeopardize such long-term experimental studies by failing to delay the commencement of fluoridation by the short period required to assess the caries rates in the children in the control area.

(70) In any event, the criticism is rather meaningless as far as the Grand Rapids study is concerned when we realize that the base-line examination in the control city of Muskegon showed that caries prevalence in that city is of the same order as in Grand Rapids.

Comment. Mr Fuller mentions the Grand Rapids trial-the trial which showed the best comparability of caries rates between the test and the control cities. He ignores the 'smoothing' of the initial rates in the Newburgh-Kingston trial (pp. 54-5) and the fact that, at the time fluoridation was instituted in Brantforcl, the degree of comparability of the rates in that city and in Sarnia, its 'fluoride-free' control city, cannot be established (pp. 39, 44). He also ignores the gross differences found in caries rates during the initial examinations in Evanston and its control city (p. 21; Fig. 3, p. 22).

(71) In attacking the Evanston-Oak Park study, Sutton bemoans the lack of information about the design of the study and phrases such as 'It is not clear - - .', 'It is not understood - - .', '(It) was not stated - - - ' give the lead to questions and speculations that follow. But why not adopt the simple expedient of writing to the workers concerned and so finding out instead of speculating? This attitude is typical of the book.

Comment. The ten reports from this study which dealt with caries rates, a total of more than sixty-five pages in journals, provided ample space for the authors of this study to publish details both of their methods and of the results they had obtained. It was felt, therefore, that data which they had not published during the twelve years which had elapsed since it was obtained — such as the caries rates of the younger children attending the different types of school (p. 34) and the caries rates of the deciduous teeth in Oak Park (p. 24)—would, almost certainly, not be disclosed in correspondence. The reasonableness of this assumption has been borne out by the failure of Doctors Blayney and Hill, in their review of this monograph, to mention these, and other, omissions which were pointed out.

(72-3) And typical also is the quibbling over details that do not detract one iota from the part that fluoridation has played in these areas in reducing dental decay(72). ‘The total tooth surfaces considered ... should be 58,325, not 58,352’ says the author, and also ‘... the mean of these values for 1946 ... is 150.09, not 149.76’(73), Dear me, Dr Sutton, how dreadful!

Comment. Errors in the tables of a research report may inadvertently appear, but should be rare, and they should be reported and corrected as soon as is practicable. To refer to such errors as 'quibbling over details' indicates that Mr Fuller does not realize, or in this ease does not admit, the need for accuracy in a research report.

The first of the numerical errors mentioned was present in Table XII (Hill et al., 1957a). Mr Fuller omits to mention that, in the same table, the D.M.F. rate per hundred surfaces for the fourteen-year-old children in 1946, which was shown in a previous paper (Hill et al,, iy) as 15,09, was altered to 15.92. As a result of this small change in the caries rate, the percentage 'Differences from 1946' were increased from 1.78 to 6.8 (6.8 should read 6.91) in 1949, and from 7.62 to 12.44 in 1952 (p. 23). No explanation for this change was given-indeed, the fact that a change had been made was not mentioned.

In spite of Mr Fuller's opinion to the contrary, this is a clear example why even small errors in the caries rates should be noted. Small errors or changes in these rates may produce marked changes in the results reported when these are expressed as percentage changes—as is the case in all these studies.

The second error referred to by Mr Fuller, the incorrect rate of 149.76, was originally pointed out on page thirty-one of this monograph. It is the smaller error of two which arose when the authors of this study altered their original results (p. 30), and is an error in computing the amended rates (p.31) in the 1952 report of Hill et al. This incorrect figure was repeated in the 1954, 1956, and 1957a reports.

(74-5) And then we come to the Newburgh.Kingston stud'. Prominence is given to the different composition @1 the waters at Newburgh as compared with the control riss of Kingston(74), and this is cited as the reason why the latter is unacceptable as a control. But once again Suitos omits any reference to a key report, that by Dean, Arnold, and Elvove of August, 1942, listing caries prevalence rates in communities where the variables in the domestic sealer mentioned by Sutton varied to a greater degree than hitween Newburgh and Kingston without caries prevalenie being markedly affected(75).

Comment. Mr Fuller suggests that the variables in the domestic water are of little importance in a fluoridation study, and, therefore, that the differences (p. 48-9; Fig. 7, p. 49) between the water supplies of Newburgh and Kingston are unimportant. In support of this contention he cites the findings of Dean, Arnold and Elvove (1942). However it is clear that his opinion was not held by Dr Ast, the senior author of the Newburgh study, in 1943 (p. 49) when he emphasized the importance of the comparability of the ‘chemical composition of past and present water supply’. Nor was it shared by the American Water Works Association (1949) when they stated that the experimental verification of the fluoride-dental caries hypothesis ‘obviously necessitates the use of a nearby “control” city with a water supply comparable in all respects to that to which fluoride is being added.’ It should be noted that not only was the composition of the Kingston water considerably different from that of Newburgh (pp. 48-9; Fig. 7, p. 49) but the authors (Ast et al., 1950) ignored this fact and said (p. 48) that the waters ‘were comparable and have remained so, except for the addition of sodium fluoride in Newburgh's supply.’

(76) The author complains of bias in the manner in which souse results are presented but, as can be seen, he displays bias himself in the choice of articles he quotes and in his omission to read others.

Comment. Mr Fuller has made the assertion that bias was displayed by the choice of articles quoted. It is assumed that he meant a bias against literature in favour of fluoridation, but the unreasonable nature of this accusation is obvious when the following facts are considered: There were sixty-seven references given in the first edition of this monograph. Thirty-one of these were to original papers from fluoridation trials, eleven were to papers by authors of fluoridation studies or by strong proponents of this measure, and six were official reports. Of the remaining nineteen, thirteen references were made to statistical or other 'neutral' studies, and only six references were made to papers which could conceivably be considered to question any aspect of fluoridation. Moreover, only brief mention was made to these six papers, about half a page in all, of the seventy-two pages of the text being devoted to them.

It can be seen, therefore, that the observations made in this study of fluoridation trials are founded, almost entirely, upon statements made in the original reports from these trials and by those who advocate this measure. Mr Fuller's charge, that bias is shown in this monograph, is in direct contrast to the opinion of the reviewer for the Journal of the Dental Association of South Africa (15 March 1960) who said that ‘The author proves himself to be completely without bias; although he exposes numerous errors, omissions and misstatements in this evidence, he does not condemn fluoridation out of hand.’

(77) It is not surprising, therefore, to see hint fall into the familiar pattern of the antifinoridationist. Those who question fluoridation are given the familiar title of 'eminent authorities,' a distinction not afforded anyone else.

Comment. Those termed ‘eminent authorities’ (p. 5) were: (a) Sir Stanton Hicks, who, for many years, was Professor of Physiology and Pharmacology in the University of Adelaide, and Scientific Advisor on Foodstuffs and Feeding to the Australian Military Forces. (b) Dr Hugh M. Sinclair, Vice-President of Magdalen College, Oxford, and formerly Professor of Human Nutrition at that University, and his co-author, Dr Dagmar C. Wilson, the author or co-author of many original papers on dental caries and fluorides. (c) The remaining authority mentioned as questioning the safety of fluoridation (p. 5) was the late Professor Harold K. Box who was, correctly, described in paragraph 119 of the Report of the New Zealand Commission of Inquiry (1957) as ‘an international authority on periodontal disease’.

It is of interest to note the next paragraph in that New Zealand Report where mention is made of the paper of Professor Box from which the quotation on page five was taken (Box, 1955). It states: ‘120. Dr Cunningham, Head of the Department of Periodontology at the Otago University Dental School, produced an article published by Dr Box in 1955 in which he stated: “I have never made a survey of gingival and periodontal diseases in any area where the water was naturally fluoridated ... and I have written or published nothing on this subject.” (Dental Digest. 61: 172-April 1955.)’

That statement, read without reference to its context, suggests that Dr Box did not express an opinion regarding the possible effects on the periodontal structures of the ingestion of fluorides. However, in the concluding paragraph of that paper, he stated: ‘At the present time, the available findings on gingival and periodontal diseases, as revealed by survey, are totally inadequate. It is my considered opinion that the artificial fluoridation of water supplies, on a wholesale basis, should not be advocated or adopted until fully sufficient findings show that there are no harmful sequelae from a gingival or periodontal standpoint.’

This paper was entitled ‘Fluoridation and periodontal disease’. It occupied only one page, and the opinion which Professor Box expressed in the concluding paragraph was also shown, in almost the same words, in a summary, its large type, which preceded his paper. As this paper was ‘produced’ and, presumably, read, the opinion which he expressed in such strong terms could not have escaped the attention of the New Zealand Commission of Inquiry (1957). Therefore it is surprising that that Commission, instead of giving prominence to the opinion of Professor Box, whom it recognized as ‘an international authority on periodontal disease’, should fail even to mention his ‘considered opinion’.

(78) It is surprising, however, to see him serve his ends by quoting Feltman's study on the use of fluoride tablets. This study lacks the very control that one would expect Sutton to consider essential.

Comment. Mr Fuller disparages the work of Feltman on the use of fluoride tablets. However, the New Zealand Commission of Inquiry (1957) said that ‘certain preliminary controlled studies by Held & Piguet (1954) in Switzerland and by Feltman (1951) in the United States are promising.’ The paper by Feltman (1956), which was quoted on page sixty-six, was stated to be a ‘progress report’. His findings (p. 66) were mentioned because data from the Evanston trial were compatible with a continuous and marked decline in the rate of eruption of the first permaneni molars during the first four to five years of fluoridation (pp aG-fl). Because Feltman's results were only progress ones, and because the authors of the Evanston study, Hill et of., failed to publish this type of data after 1951 (pp. 27, 66; Fig. 4, p. 27) the suggestion inherent in both these results was treated with reserve, when preparing this monograph, and it was stated: ‘Of course, if fluoridation results in the eruption rate of teeth being retarded . . .’ (p. 66).

It should be noted that no comment was made by Doctors Blayney and Hill (in their review of this book) on this suggestion of a decline in eruption rate, even though it was illustrated in Figure 4 (p. 27).

(79) As one would expect, there are no bouquets for the New Zealand Commission of Inquiry, one complaint being that “no mention was made of the employment of a statistician to assist its members in evaluating [the] numerical data.” Had the author inquired, he would have been told that the Professor of Biochemistry on the Commission was well versed in biometrics, and that scientific witnesses quickly discovered that tables were unacceptable unless they contained complete details including standard errors, so that he could evaluate data statistically for himself and the Commission.

Comment. If this is so, it is surprising that the Commission (New Zealand Commission of Inquiry, 1957) stated (p. 69) that ‘We have found nothing to invalidate the statistics or cast doubt on their reliability.’

(80) Finally, a warning to those reading this book, lest they be misled by the polemics and the array of figures. Please note that Sutton's conclusions in part 2 (which forms the greater part of the book) are confined to variations in the prevalence of dental decay in control cities and not to the cities where fluoride has been added.

Comment. The conclusions in Part Two were not 'confined to variations in the prevalence of dental decay in control cities'. Those 'reading this book' will, no doubt, realize-without this ‘warning’ — why emphasis was placed on these cities, for it is unlikely that they would not have read (p.5) the title of Part Two: ‘Fluoridation trial controls: errors, omissions and misstatements’.

(81-2) What of the places where fluoridation has been adopted? Sutton does not dispute the fact that the prevalence of dental decay has been substantially reduced in the fluoridation cities of Grand Rapids, Newburgh, Brantford, and Evanston(81), nor does he mention that these good results have been confirmed by several independent studies in tin U.S.A., and also in Tasmania, Brazil, Japan, Germany,. Sweden, and at Hastings in New Zealand(82).

Comment. The claim that ‘the prevalence of dental decay has been substantially reduced’ in these test cities, as a result of fluoridation, was questioned in the concluding statements of both Part One and Part Two (Pp. 4, 71). Mr Fuller’s statement that these claims were not disputed is incorrect. The fact that he made such a statement supports the conclusion reached in the first comment on his review—that he had read this monograph only superficially.

In December 1958, a list of cities with fluoridation schemes in operation was supplied by the Dental Health Officer, World Health Organization (F. B. Rice, personal communication). In this, no control cities were shown for the fluoridation projects in four of the countries mentioned by Mr Fuller, namely Brazil, Japan, Germany, and Sweden. No control was attempted in the Tasmanian scheme (Brothers, i956). The control for the Hastings project was abandoned, the reason given for this action being that 'the two cities were not comparable since the basic soil type in the Napier area is different to that in the vicinity of Hastings' (Ludwig, i958). As all these artificial fluoridation projects were conducted without controls, it should be obvious why they were not mentioned in Part Two for, as its title states, it considers fluoridation trial controls. The meagre results pubfished (p. 6) from these and other projects cannot be said to ‘confirm’ the results of the main studies on artificial fluoridation—in any case uncertain results cannot be confirmed.

(83) The validity of the results from Hastings, incidentally, has been checked by the Applied Mathematics Laboratory of the New Zealand Department of Scientific and Industrial Research.

Comment. It is frequently not recognized that the validity of results depends not only on the accuracy of the mathematical computations but also on the design of the experiment. In discussing the mechanism of the Evanston trial, Blayney and Tucker (1948) said that ‘A study of this nature must have an adequate control.’ The Hastings project has no control for, soon after it was commenced, the control was abandoned. Sir Ronald Fisher's statement on this subject is of very great importance in considering the results published from all these fluoridation projects (Fisher): 'If the design of an experiment is faulty, any method of interpretation which makes it out to be decisive must be faulty too.'


CONCLUSION

IN this second edition, consideration has been given to criticism published by five men who, by their close association with fluoridation investigations, should be exceptionally well equipped to comment. It should be noted that these criticisms make practically no relevant comment on the points raised concerning the Grand Rapids and the Newburgh trials, nor on most of the matters mentioned by the author in discussing the Evanston trial.

The Editorial in the February 1960 issue of the Australian Dental Journal inferred that the first edition was essentially an 'unearthing' of 'typographical errors, slips in arithmetic and minor inconsistencies'. In the light of the comments made on the criticisms published in these book reviews, the reader must decide whether this inference is a true one. It is pertinent to mention that, in an 'Occasional Survey' published in the Lancet entitled 'Fluoridation: the present position', it was stated that the first edition showed 'that the American trials claim more and prove less than the published results at first suggest.'

In the final paragraph of Part One, the opinion was expressed that 'It is possible that a case for fluoridation can be solidly based'. However, investigation of the published criticisms that have been reprinted here has considerably strengthened the conviction, which was expressed in the Summary of Part Two, that ‘The sound basis on which the efficacy of a public health measure must be assessed is not provided by these five crucial trials.’


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