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Draft NHMRC Public Statement 2017: Water fluoridation and human health in Australia submission

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Question 1
Q1. A. The draft Public Statement is presented in a format and manner that is useful, and is easy to read and understand: 
Comments on a particular section of the Public Statement: 
Question 2
Q2. A. The boxed ‘NHMRC statement’ (page one) in the draft Public Statement is justified and supported by the evidence in the Information Paper: Effects of Water Fluoridation on Dental and Other Human Health Outcomes : 
Q2. B. If disagree or neutral, please provide recent scientific evidence not previously submitted to NHMRC. Refer to what is ‘Out of scope for this public consultation’ below: 

Please see the response to Question 5 regarding the need for additional information.

Question 3
Q3. A. For policy makers, the draft Public Statement provides sufficient information to support decision making in your jurisdiction or local area: 
Comments on a particular section of the Public Statement: 
Question 4
Q4. How could the Public Statement be effectively disseminated?: 
Question 5
Q5. Is there any other information that may be useful to include in the draft Public Statement? If so, please provide details: 

Yes. The Public Statement will be disseminated to a diverse audience and most likely read as a stand-alone document, rather than in conjunction with the Information Paper. Given that lack of contextualisation, some sections require additional information. Firstly, the boxed statement: “NHMRC ‘strongly’ recommends…fluoridation”, is likely to be interpreted as a finding of strong evidence. Rather, the evidence available to assess the effects of water fluoridation will likely always come from observational studies which are largely of low methodological quality (Jack et al., 2016); as found in other reviews (e.g. Parnell et al., 2009; Ejiofor et el., 2015). Hence, “decision-makers must recognise these limitations” of observational studies (Jack et al., 2016, p.6). Such studies do not measure actual daily (mL) consumption of fluoridated water, while findings for non-fluoridated regions are confounded by their diffused consumption of fluoride in foods and beverages. Therefore, a brief statement on the limitations of findings from observational studies should be included in the ‘Scientific Evidence’ section. Also, the intended audience are unlikely to be aware that the Grade approach applied by the NHMRC enables researchers to make discordant ‘strong recommendations for low quality evidence’ (WHO, 2014). Therefore, a plain language statement on Grade (even as a footnote) should be included.

Secondly, the Public Statement section on ‘fluorosis’ clearly explains that its reduction has been attributed to the promotion of low fluoride concentration toothpastes and public health messages around their appropriate use. However it should not be assumed that there is consumer awareness and health literacy around those variables, including within  linguistically diverse communities. The statement: “minimal use of low fluoride concentration toothpaste is advisable for children in fluoridated areas” should be included; particularly given the risk of additional exposure to fluoride from food and beverages, and, given that the cited study samples (Public Statement refs. 3, 4, 6) are not representative of the national population.


Ejiofor Z, et al. (2015). Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews, Issue 6: CD010856.

Jack, B., Ayson, M., Lewis, S., Irving, A., Agresta, B., Ko, H., Stoklosa, A. (2016) Health Effects of Water Fluoridation: Evidence Evaluation Report, report to the National Health and Medical Research Council, Canberra. (latest version).

Parnell, C., Whelton, H., & O'Mullane, D. (2009). Water fluoridation. European Archives of Paediatric Dentistry, 10(3), 141-148.

WHO. (2014). ‘Strong recommendations when the evidence is low quality’. World Health Organization handbook for guideline development, Ch14, 2nd ed., pp.169-12.

Page reviewed: 9 November, 2017