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Draft NHMRC Information Paper: Effects of water fluoridation on dental and other health outcomes submission

ID: 
17
This submission reflects the views of
Individual Background: 
Science and elected Councillor
Personal Details
First Name: 
Lisa
Last Name: 
Intemann
Specific Questions
Q1. A) Is the draft Information Paper presented in a manner that is easy to understand? : 
Disagree
Q1. B) Please provide details regarding your response to Question 1A: 
Plain Language Summary

My comments here address the first stated purpose of this consultation, namely
“To seek feedback on the draft Information Paper to find out whether NHMRC
has presented the information in a manner that can be understood by and is
relevant to the general audience.”
The DIP is fairly easy to read and understand as far as it goes.
But by any objective reckoning the DIP utterly fails to be relevant to the general
audience, who we assume would prefer the whole truth and not just half the
story.
The DIP is irrelevant to those people who want information beyond the fairy
tale, concerning a genuine assessment of the known potential risks. The
document is entirely focussed on a task of PR that it effectively forgets that the
main goal for NHMRC is to provide advice based in science.
The DIP will be irrelevant to anyone who wants to know the whole story and not
just the half which it suits someone to give you because it makes their life
easier. It will be irrelevant to anyone interested in the ethics of fluoridation,
concerning the real-life risks and benefits for both teeth and our general health.
For it is not true as the DIP suggests – that there is a “long history of research”
showing water fluoridation helps reduce tooth decay. Rather, the better
evidence (and especially from the Cochrane Collaboration 2015) suggests that
the history of fluoridation research is quite shabby, characterised by mostly
unsystematic low quality research.
Rather than responding constructively to the new information from the
Cochrane Collaboration by determining to do better in future, the DIP renders
itself irrelevant by perpetuating the old problems – duplicating poor practices
through simplistic research and gap-ridden reporting, asserting its position by
presuming to know better about global findings and improving research design
than even Cochrane.
That makes the DIP irrelevant to whoever wants Australia to take its research
forward, because it takes the quality of our research backward: reverting to
simple cross-sectional studies in one time; forgetting to address bias with
rigour; failing to adopt a strategic approach to fluoridation research.
The DIP is irrelevant to guide policy because it is scientifically incomplete and
naïve, failing to take transparent account of its own bias and limitations, simply
presuming its assumptions remain true for the sake of consistency. This is
especially true regarding non-dental health effects, with the DIP claiming water
fluoridation is “safe for general health” despite the growing body of evidence
showing the potential for various adverse effects on human health.

All those statements are supported below by examples, all of which show that
the DIP as it stands is irrelevant because it is only half done, half baked.
The DIP will remain irrelevant to the general reader unless and until it is
presented in a properly scientific manner: stating and assessing claims
objectively; stating and accounting for its own limitations; striving always to
improve research design. The DIP will remain irrelevant while ever it remains an
exercise in consistency and not scientific rigour.
p.1 “These chemicals are recommended for use in the NHMRC Australian
Drinking Water Guidelines, and their management and safety are monitored by
state and territory governments.”
That statement is misleading thus irrelevant to the needs of the audience of
Australian consumers of fluoridation chemicals because the wording suggests
that the chemicals are safe for the consumer.
The chemicals used in water fluoridation – hydrofluorosilicic acid (H2SiF6) or its
sodium salt (Na2SiF6) - have never been comprehensively assessed for safe
human consumption. These chemicals have never been subject to toxicological
assessment and therefore it is false to say their “safety” is being monitored. I
reserve the right to make these statements about fluoridation chemicals
(despite your attempted prohibition on the topic) because NHMRC has itself
raised the subject in the DIP.
It is dishonest and misleading to suggest that the fluoridation chemicals are
properly managed for safety of use
p.2 “Toothpastes and some foods are another source of fluoride, and NHMRC
took this into account as the evidence was reviewed and analysed.”
That statement is misleading. NHMRC has never undertaken a study of fluoride
intake from all sources and compared contemporary intake with evidence of
adverse effects. That is despite a specific recommendation from the 1991
NHMRC fluoridation review that actual intake be measured and monitored
under Australian conditions – which has never been done.
p.3 “This information Paper [considers these studies] and “makes conclusions
based on all these reviews”.
That statement is incorrect because actually the paper rejects certain findings of
the Cochrane Review (regarding the need for more sophisticated research) and
effectively ignores the recommendations of the York Review regarding the need
for targeted research into adverse health effects.
p.3 “All of the studies in previous reviews … found that water fluoridation
reduces tooth decay by 26-44% in children, teenagers and adults.”
That statement is misleading and not easy to understand because of (a) not
providing an absolute measure (e.g. water fluoridation often leads to less than
one tooth difference in children), and (b) exaggerating the evidence in adults
(the finding of Slade 2013 was less than 3 teeth difference in seniors out of an
average 21 teeth lost or decayed, and a difference of just over 1 tooth in
adults). To present the information in percentages only, and in cases
exaggerated at that, it not aiding the goal of helping people understand what’s
really at stake from fluoridation.
p.3 Dental fluorosis – The precautionary principle and the edicts of the
Australian Drinking Water Guidelines require an attitude of safety first. It is not
objectively true to say that very mild to mild dental fluorosis “has no effect on
the function of teeth. Research suggests that this is unlikely to be of concern to
those affected.”
That statement is misleading and therefore irrelevant to the audience because
in fact there is considerable research, such as the report of the US National
Research Council 2006, suggesting that people are psychologically affected by
fluorotic marks on their teeth, that fluorosis can represent a weakening of tooth
structure, and moreover that dental fluorosis might be just the visible sign of 

adverse effects taking place in other organs. It is irresponsible of NHMRC to
downplay the significance of dental fluorosis when (a) its incidence is increasing
and can be expected to continue to increase under nation-wide fluoridation, and
(b) it may be the signal for other adverse bodily effects. The Draft Information
Paper will be irrelevant to the extent that it ignores these other sources of
information which it has deliberately excluded from consideration.
p.4 “International studies in the review showed that fluoride in drinking water is
linked to the amount and severity of fluorosis. Water fluoridation levels in the
countries of these studies are much higher than in Australian drinking water,
however, making it difficult to apply these results to Australia.”
That statement is misleading and lazy therefore irrelevant because dental
fluorosis displays a dose-response relationship with consumption of fluoride and
therefore results from intake can be reliably extrapolated, or safety factors
applied. The application of safety factors to a known Adverse Effect Level is
common practice in toxicology and recommended by the Australian Drinking
Water Guidelines. There is no good reason for the NHMRC to continue
rejecting health studies from places with different fluoridation levels because
toxicology anticipates such situations and provides for it through the use of
safety factors.
As it is now well known that fluoride protects teeth by topical application without
the risks to health from consumption, the whole idea of water fluoridation is
irrelevant and indeed unethical. The supporting documents themselves admit
there is no evidence of fluoridation addressing disparity so the DIP is unethical
and irrelevant to real life and good science for purporting otherwise.
p.4 “The review found that water fluoridation at levels used in Australia does not
cause any negative health effects.”
That statement is false therefore irrelevant. It should more rightly say that the
review was unsuccessful in identifying evidence of potential harms to health
under the adopted search regimen. To which it should of course be added that
NHMRC will engage its own research into actual intake and the toxicology of
main known areas of potential health problems, namely bone, kidney and
sensitivity. Until proper toxicological studies are done, there can be no
legitimate – relevant to the real world - claim about the safety of consuming
fluoride.

Introduction

p.5 “This Information Paper provides Australians with a summary of evidence
on the health effects of the addition of fluoride to drinking water.”
That is a false statement. The DIP provides a summary of only certain aspects
of research into health effects, namely those conforming to the limited criteria
that were chosen by NMHRC. The DIP is not a comprehensive assessment and
should not be portrayed as such.
In its 1991 Review of Fluoridation, The Effectiveness of Water Fluoridation,
NHMRC adopted an honest approach to fluoridation issues - recognising the
need to go beyond a mere survey of available evidence and adopt a pro-active
approach by doing its own research.
Specifically:
p 17, s.D Recommendations – NHMRC should “develop monitoring
mechanisms to document total fluoride intakes by adults with a view to
estimating levels of deposition in bone”.
s. 6.4, p 84 – “It would not be surprising if there were some undetected cases of
skeletal fluorosis in the Australian population in individuals with pathological
thirst disorders and/or impaired renal function. However, the matter has not
been systematically examined. This matter should be the subject of careful and
systematic review.”
s. 6.5, p 84 – “It is desirable to look in a rigorous fashion whether the vague 

constellation of symptoms which are claimed to result from ingestion of
fluoridated water can be shown to be reproducibly developed in these
"susceptible" individuals. These claims are being made with sufficient frequency
to justify well-designed studies which can properly control for subject and
observer bias.”
s. 6.5, p. 84 – “During the conduct of any future epidemiologic studies, it will be
very difficult to determine the levels of fluoride to which cancer sufferers and
selected controls have been exposed, but systematic efforts to determine this
are highly desirable. These issues also deserve the attention of a
multidisciplinary group, backed by sufficient funds to initiate rigorous studies
which can contribute information to the international knowledge base on these
matters.”
S 8.3 – “Total fluoride intake and public health: “There are no Australian reports
which permits the Working Group to precisely estimate, with confidence, the
current intake of fluoride which various aged individuals are ingesting, nor the
differential amount of fluoride which is being stored in Australian skeletons, in
fluoridated and unfluoridated areas. Australia is reliant on overseas studies for
assumption that these amounts are likely to be small enough to present no risk
to long term health. The evidence arising from the NTP studies which have led
the NHMRC Committee on Toxicity to classify fluoride as an "equivocal"
carcinogen in high dosage in rats makes it imperative that public health
recommendations in the future be based on accurate knowledge of the total
fluoride intake of Australians. Accordingly, the Working Group believes that
proposals to monitor this load should be developed for various indicator
populations within Australia and that these studies should take account of the
range of deliberative and involuntary intakes which are occurring in both normal
and susceptible individuals, in both fluoridated and unfluoridated areas. The
proposals should be developed by a multidisciplinary group comprising
epidemiologists, toxicologists and statisticians, and the research should be
coordinated by the new NHMRC Environmental Toxicology Research Unit.”
s. 8.4, p 108 – “Dental fluorosis is a sensitive indicator of storage of fluoride in
teeth during the developmental stages of tooth formation, but does not indicate
the amount of fluoride which is being incorporated into bone throughout adult
life. … Studies of bone fluoride collected at autopsy in selected individuals
could provide needed reassurance that the current policy is not resulting in
hazardous levels of bone accumulation.”
Recommendations for specific research were echoed in the 1999 NHMRC
review of fluoridation, adding furthermore:
Ch 4 p.9 “Fluoride is largely excreted via the kidneys. Patients with renal failure
have plasma levels three times higher than normal individuals from the same
region. The effect of such high plasma levels on bone merits investigation.”
Ch 8 p.6 “Research into the role of fluoride in biomineralization is needed,
including the interaction between mineral, matrix proteins and fluoride, in situ,
the mechanism of mineralisation under a fluoride regime, and the molecular
basis of fluoride’s effect on cellular proliferation and differentiation.”
Plans were subsequently made by NHMRC to conduct the relevant studies but
these were never undertaken due to “insufficient resources” (NHMRC to NSW
Health 24 Feb 2005).
It is disingenuous of NHMRC to ignore these recommendations and the known
potential risks to health, pretending to the Australian community that water
fluoridation is safe while being fully aware that there are concerns needing
study. This situation renders NHMRC’s advice irrelevant.
In the words of the NHMRC 1991 review, “Australia has, more than most
countries, invested heavily in fluoridation as a public health measure (and this
has achieved beneficial results), but it has contributed less to the fundamental
body of knowledge which is, and will continue to be, essential if water
fluoridation is to continue as a national and regional preventive strategy.”

There is now a large and growing body of international clinical, epidemiological
and laboratory evidence which is strongly suggestive that low levels of fluoride
have adverse health effects on some members of the population: specifically,
that in fluoridated areas there is an increase in the prevalence and severity of
dental fluorosis, that skeletal fluorosis may be a problem, especially for people
with kidney malfunction, and that some people suffer from hypersensitivity,
intolerance reactions and chronic poisoning.
NHMRC will continue to render its advice irrelevant unless and until it abandons
its obsession with “consistency” and addresses instead the first clause of its
mission statement namely, to “fund high quality health and medical research
and build research capability.”
DIP p.7 “NHMRC is responsible for ensuring that Australians receive the best
available, evidence-based advice on health and on preventing, diagnosing and
treating disease.”
That statement is irrelevant to the extent that NHMRC fails to live up to its
responsibilities, instead making its decisions based on recognisably poor quality
evidence.
Those comments suffice as examples of how irrelevant the DIP is to real life
due to accepting such low standards for evidence and failing to do the research
its own report recommended in 1991.

Q2. A) Is it clear how NHMRC reviewed the health and dental effects of water fluoridation? : 
Disagree
Q2. B) Please provide details regarding you response to Question 2A: 

The DIP gives the impression that its conclusions are based on the best possible evidence of lack of harm. In
fact the conclusions are based on lack of finding good quality evidence, and lack of commitment to NHMRC
doing its own research to satisfy itself about known health concerns relating especially to bone, kidney and
sensitivity. NHMRC is playing fast and loose with the health of Australians, but this is not made clear in the
DIP.

Q3. A) Is the Fluoride Reference Group’s interpretation of the evidence clearly described in the draft Information Paper?: 
Disagree
Q3. B) Please provide details regarding your response to Question 3A: 

See answer above

Q4. Is there additional evidence on the dental effects of water fluoridation that should be considered?: 

Fluoride works topically.

Q5. Is there additional evidence on any other health effects of water fluoridation that should be considered in the draft Information Paper?: 

The DIP additionally gives no consideration to the CUMULATIVE EFFECTS of a lifetime drinking
fluoridated water, food etc.

Page reviewed: 4 July, 2017