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

This submission reflects the views of
Please add further information: 
Public health dentist, Alice Springs. National Convenor of Oral Health Special Interest Group of PHAA, National Rural Health Alliance representative on the Australian Health Care Reform Alliance Executive, member of National Oral Health Alliance committee
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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: 
Overarching/General comments on the Public Statement: 


I wonder why the recommended range has been extended beyond 0.8mg/L to 1.1mg/L given the accompanying greater risk (fourfold pp40) of fluorosis? That’s my concern with the boxed ‘NHMRC Statement.’ What is the evidence for it and what is the risk of public reaction to it?

I understand the need to be as concise and definitive as possible but that increases risk of the information being seen as confusing contradictory eg on fluoride sources. See 1.C below

Comments on a particular section of the Public Statement: 
Importance of community water fluoridation

‘Fluoridated water is the major source’ etc seems potentially at odds with ‘only very small amounts are needed………taking into consideration fluoride in other sources………’ in the next section. Could be further explored and clarified.

‘Having healthy teeth requires access to fluoridated water, a healthy diet, good oral hygiene  etc…..’ is a general oral health promotion message. ‘REQUIRES’ is perhaps too specific/dogmatic? ‘Is most often associated with’ would seem more accurate or ‘generally requires’ but that would open the door to all sorts of interpretation. Given different lifestyle /behaviours at least some of the factors would be superfluous to having healthy teeth.

There’s no mention of critical role of simple sugars in tooth decay in the Statement, nor of how fluoride works to counteract their effects both systemically and topically

Access to fluoridated drinking water in Australia

Wonder if last para should refer to ‘…the appropriate operational levels (plural)… given that levels may vary across a state or territory? Wonder too if for all states and territories one government health authority makes state-wide decisions?

A related comment that in Figure 1 the relatively low 78% coverage in the NT is almost certainly because Alice Springs (popn 29,000) has a naturally occurring rate of around 0.5mg/L and an decision was taken many years ago now (1987) to cease adding fluoride because of the high rates of fluorosis that had been occurring in local children drinking fluoridated water at 0.6-0.8mg/L.

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: 

Commented above on the F range.

You have ruled out accepting non-scientific data and your text emphasises ‘there is no reliable evidence of an association etc’. To an extent you are inviting contrary responses by adding the qualifier ‘reliable’ but I guess it’s essential.

Question 3
Q3. A. For policy makers, the draft Public Statement provides sufficient information to support decision making in your jurisdiction or local area: 
Overarching/General comments on the Public Statement: 

I’d like a considerably more comprehensive document if I was a policy maker, but acknowledge that Statement appears to cover all the key community concerns related to health and safety.

There’s nothing relating tooth decay reductions to fluoridation levels (dose response) in terms of guiding policy makers in setting appropriate levels.

Nothing on cost benefit analysis.

Comments on a particular section of the Public Statement: 
NHMRC’s role in community water fluoridation

We have a number of remote communities in the southern NT, including Tennant Creek, with naturally occurring F levels of 1.2-1.5mg/L and where fluorosis is endemic, sometimes moderate. So I wonder at the validity of saying ‘…this includes a guideline value of 1.5mg/L that should not be exceeded. This protects children from the risk of dental fluorosis.’  Could it be reworded?

Question 4
Q4. How could the Public Statement be effectively disseminated?: 
Who would find the draft Public Statement useful?

Policy makers (backed by Information Paper), governments (COAG), Public health services, advocates and organisations, Rural and Remote NGO’s, Aboriginal and Torres Strait Islander organisations, , Local Councils (notably in Queensland), concerned members of the public, dental/oral health industry/academic institutions.  Obviously would need to be disseminated and accessible both in hard copy and electronically. One-off public launch would be in order.

General comments

Clearly this statement on its own won’t address the multiple concerns of people opposed to fluoridation but it strengthens the hand of fluoridation advocates. I would foresee the need for a considerably more nuanced ‘local’ approach and information in areas where fluoridation is being debated. This document would be a critical tool in the armamentarium of fluoridation proponents.

Question 5
Q5. Is there any other information that may be useful to include in the draft Public Statement? If so, please provide details: 

Grateful for the action of the NHMRC and the Fluoride Reference Group in undertaking this valuable public health work and also for engaging the community through initiating this consultation process.

Page reviewed: 9 November, 2017