October 2000

The following review by the Associate Editor of the British Medical Journal, Douglas Carnall, appeared on the same day that the British Medical Journal published the findings from the York Review (Fluoridation of Drinking Water: A Systematic Review of its Efficacy and Safety).

Carnall's response to the study is far different than one would expect after reading the headlines and spin which the report generated (e.g. "Great Majority of Research Favors Fluoridation"). Concluding his review, Carnall states, "Previously neutral on the issue, I am now persuaded by the arguments that those who wish to take fluoride (like me) had better get it from toothpaste rather than the water supply."

See this review on the web at http://www.bmj.com/cgi/content/full/321/7265/904/a

British Medical Journal

October 7, 2000

Reviews

Website of the week

Water fluoridation

Fluoridation was a controversial topic even before Kubrick's Base Commander Ripper railed against "the international communist conspiracy to sap and impurify all of our precious bodily fluids" in the 1964 film Dr Strangelove (www.indelibleinc.com/kubrick/films/strangelove/). This week's BMJ shouldn't precipitate a global holocaust, but it does seem that Base Commander Ripper may have had a point. The systematic review published this week (p 855) shows that much of the evidence for fluoridation was derived from low quality studies, that its benefits may have been overstated, and that the risk to benefit ratio for the development of the commonest side effect (dental fluorosis, or mottling of the teeth) is rather high.

Supplementary materials are available on the BMJ 's website and on that of the review's authors (www.york.ac.uk/inst/crd/fluorid.htm), enhancing the validity of the conclusions through transparency of process. For example, the "frequently asked questions" page of the site explains who comprised the advisory panel and how they were chosen ("balanced to include those for and against, as well as those who are neutral"), and the site includes the minutes of their meetings. You can also pick up all 279 references in Word97 format, and tables of data in PDF. Such transparency is admirable and can only encourage rationality of debate.

Professionals who propose compulsory preventive measures for a whole population have a different weight of responsibility on their shoulders than those who respond to the requests of individuals for help. Previously neutral on the issue, I am now persuaded by the arguments that those who wish to take fluoride (like me) had better get it from toothpaste rather than the water supply (see www.derweb.co.uk/bfs/index.html and www.npwa.freeserve.co.uk/index.html for the two viewpoints).

Douglas Carnall
Associate Editor
British Medical Journal

Of further interest:

The following are the key findings of the York Review according to Dr. Peter Mansfield who served on the Review Team's Advisory Panel:

"Key Review Points:

* Evidence quality was poor, and quantity very limited;

* Most studies could have been biased because dental assessors (of both caries and fluorosis) usually knew where the study subjects lived;

* Dental benefits are less (15%) than have been claimed (25-60%);

* Dental disfigurement (12.5%) is far higher than expected;

* There is almost no evidence for a reduction of social class inequalities by water fluoridation;

* Far too little evidence exists to justify any assumption that artificial fluoridation is as safe as 1 ppm calcium fluoride occurring naturally;

* The review does not tackle the effects of total fluoride exposure (except, by accident, its impact on dental fluorosis)."

Read Mansfield's statement in it's entirety at http://www.fluoridealert.org/p-mansfield.htm