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

This submission reflects the views of
Organisation Name: 
Australian Dental Association
Personal Details
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 : 
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?: 
General comments
  • Depending on resources, a targeted information campaign should be undertaken.
Question 5
Q5. Is there any other information that may be useful to include in the draft Public Statement? If so, please provide details: 

The ADA recognises that the Information Paper is not within the scope of public consultation. It is provided for information only. That said, the ADA can state that the ADA guidelines relating to water fluoridation found in its Policy Statement 2.2 Community Oral Health Promotion; Fluoride Use [including ADA Guidelines on the Use of Fluoride] (https://www.ada.org.au/Professional-Information/Policies/Policy-Index/ADAPolicies_Index) matches the information provided in the information paper.

The ADA supports the draft Public Statement’s reference to evidence that fluoridated areas experience lower rates of potentially preventable hospitalisations for tooth decay. 

Regarding tooth decay, the draft Public Statement says that "Recent Australian research suggest that access to fluoridated water from an early age is associated with less tooth decay in young and middle-aged adults." While this is correct, the implication is that people older than this or people who did not have access to fluoridated water from an early age will not benefit from water fluoridation. The ADA infers that the NHMRC is being cautious as the total of all permanent teeth surfaces that are decayed (D), missing (M) due to decay, or filled (F) due to decay (DMFS) scores for older Australians do not show much difference.[1] The probable reasons for caution are outlined by Loc Do in the paper referred to in the first footnote. 

However, current evidence and biological plausibility strongly suggest that adults of all ages have stronger, more decay resistant teeth as a result of fluoridated drinking water, and this benefit also applies to people from the pre-fluoride generation who grew up prior to the common use of fluoride toothpaste and fluoridated water.[2] Access to optimally fluoridated water from an early age confers lifelong benefits and reduced decay rates at any age. Water fluoridation in Australia has been highly successful with very significant reductions in dental disease because many natural water supplies in Australia have naturally low fluorine levels.

With respect to dental fluorosis, the draft Public Statement implies that water fluoridation poses a risk for the development of moderate or severe dental fluorosis, but this risk is extremely low. The draft Public Statement fails to stress the impact of inappropriate uses of fluoride toothpaste or supplements or, more rarely, high levels of fluoride occurring naturally in a very small number of water supplies in the development of aesthetically concerning dental fluorosis.[3] All sources of fluoride ingestion at critical ages can contribute to dental fluorosis.[4] The potential for an inappropriately high fluoride intake is clearly greater from sources such as (unsupervised) toothpaste and supplements than from fluoridated drinking water. Mild and very mild dental fluorosis diminishes over time but, does not adversely affect oral health or perceptions of oral health. On the contrary, mild and very mild dental fluorosis is associated with stronger, healthier teeth and a better appearance and oral health related quality of life.[5]

Should you require further comment regarding the ADA’s feedback, please contact, the ADA Chief Executive Officer, [NHMRC has removed contact information].


Yours sincerely

Dr Hugo Sachs

Federal President

Australian Dental Association

[1] Do L, Ha D, Peres MA, Skinner J, Byun R, Spencer AJ. Effectiveness of Water Fluoridation in the Prevention of Dental Caries across Adult Age Groups. Community Dent Oral Epidemiol. 2017; 45:225-32.

[2] Slade GD, Sanders AE, Do L, Roberts-Thomson K, Spencer AJ. Effects of Fluoridated Drinking Water on Dental Caries in Australian Adults. J Dent Res. 2013; 92:376-82.

[3] Pendrys DG, Katz RV, Morse DE. Risk Factors for Enamel Fluorosis in a Fluoridated Population. Am J Epidemiol. 1994; 140:461-71; amd Celeste RK, Luz PB. Independent and Additive Effects of Different Sources of Fluoride and Dental Fluorosis. Pediatr Dent. 2016; 38:233.

[4] Mascarenhas AK. Risk Factors for Dental Fluorosis: A Review of the Recent Literature. Pediatr Dent. 2000; 22:269-77.

[5] Do LG, Ha DH, Spencer AJ. Natural History and Long-Term Impact of Dental Fluorosis: A Prospective Cohort Study. The Medical Journal of Australia. 2016; 204:25; and McGrady MG, Ellwood RP, Goodwin M, Boothman N, Pretty IA. Adolescents' Perceptions of the Aesthetic Impact of Dental Fluorosis Vs. Other Dental Conditions in Areas with and without Water Fluoridation. BMC Oral Health. 2012 Feb 10; 12:4.

Page reviewed: 9 November, 2017